Minimally Invasive Osteosynthesis in Patients with Severe Combined Trauma and Polytrauma

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Introduction. Currently, in Russia, two approaches are used to provide assistance to victims with severe combined trauma and polytrauma. The full volume of multi-profile specialized surgical care, based on the concept of traumatic illness, which is used in trauma centers of the 1st level, and the reduced volume of multidisciplinary specialized surgical care, based on the concept of traumatic shock, which is used in trauma centers of the 2nd level. Since 2011 in multidisciplinary hospitals providing emergency care, level I trauma centers were organized, which include an operating department for anti-shock measures with an anti-shock operating room and an anti-shock ward (1,2). Under the new organizational system, victims with severe combined trauma (TST) and polytrauma are separated into a separate stream upon admission to the hospital, undergo damage diagnostics in the anti-shock ward, after which they are sent either to the anti-shock operating room when establishing indications for emergency surgery or to the ICU for extended diagnosis and intensive care. Thus, a situation has been created in which there are real opportunities for the use of early specialized trauma care in order to activate the victims and prevent the development of complications of traumatic illness. At the same time, the issue of assessing the severity of injuries and the condition of the victims remains unresolved, so that the surgical intervention itself does not play the role of an additional injury that worsened the severity of the condition (3,4,5)

The purpose of this study is to improve the results of treatment of victims with severe combined trauma and polytrauma, to develop a model of early trauma care.

Materials and methods. In this study, the victims were treated from 2009 to 2018 in level I trauma centers of large hospitals in St. Petersburg, which are the clinical bases of St. Petersburg State University and I. I. Mechnikov NWSMU. To assess the long-term anatomical and functional results of treatment, the Neer-Grantham-Shelton scale was used, which is based on determining the total value of parameters characterizing the state of the structure and function of the damaged limb. Due to a large number of parameters, including X-ray, functional results, trophic changes, duration of treatment, degree of disability reflecting the quality of life, the proposed method made it possible to objectively assess the quality of treatment. The results were considered good from 70 to 100 points; satisfactory-from 30 to 69 points, unsatisfactory-less than 30 points. A retrospective analysis of the strategy and tactics of treatment of 223 patients treated from 2009 to 2013 (control group) was carried out. The clinical group consisted of 413 patients with TST and polytrauma, of which 274 underwent minimally invasive osteosynthesis (MIO). The indication for MYO in TST and polytrauma was the need to fix fractures of long tubular bones (DTC) in order to create favorable conditions for rapid and lasting fusion of fractures, early functional treatment and rehabilitation of victims, and to achieve the highest possible level of quality of life after treatment. In order to determine the indications for the timing and volume of trauma care, an assessment of the severity of injuries was performed according to the NISS index and an assessment of the severity of the condition on the VPH-SP scale. According to the results of the analysis, the victims were divided into three groups. The 1st therapeutic and tactical group consisted of 110 patients with TST with a favorable prognosis of the outcome of treatment, minimal severity of injuries (≤17 points according to the NISS index) and with a stable compensated general condition (12-15 points on the VPH-SP scale). The peculiarity of this group is the absence of mortality and the minimum number of complications equal to 5%. The second therapeutic and tactical group was the most numerous. It included 188 victims with more severe TST and polytrauma with a positive prognosis, the NISS damage severity index in the range from 18 to 27 points and the severity of the condition-16-24 points according to the VPH-SP. This severity of the condition corresponds to the state of compensation for one victim (16-20 points) and the state of subcompensation (21-24 points) for others. This group occupied an intermediate position with a mortality range from 10 to 18% and a complication rate of about 36%. The third treatment and tactical group consisted of 115 victims with extremely severe polytrauma. This is a group of the most severe victims with an unfavorable prognosis, the greatest severity of injuries (≥28 points according to NISS) and a wide range of severity of the condition - ≥ 25 points according to HPV-SP, which corresponds to both a subcompensated (25-31 points), decompensated (32-45 points), and critical (>45 points) condition. In this group, the highest mortality rate is in the range of 55-58% and the highest incidence of complications is about 69%. The distribution of victims with severe combined trauma and polytrauma into therapeutic and tactical groups is shown in Table 1.

 

Table 1. Distribution of victims with severe combined trauma and polytrauma into therapeutic and tactical groups

 

Localization of fractures of long tubular bones	Therapeutic and tactical groups in accordance with the forecast of the outcome according to MFS-SA and NISS (%)			Total(%)
	Group 1: favorable (MFS-SA 12-15, NISS ≤17)	Group 2: positive (MFS-SA 16-24, NISS 18-27)	Group 3: unfavorable (MFS-SA ≥ 25, NISS ≥28)
Fractures of the LTB of the upper extremities	74 (67,3)	49(2,1)	2 (1,7)	80 (19,4)
Fractures of the LTB of the lower extremities	27 (24,5)	88(46,8)	29 (25,2)	144 (34,8)
Multiple LTB fractures	9 (8,2)	96(51,1)	84 (73,1)	189 (45,8)
TOTAL	110 (100)	188(100)	115 (100)	413 (100)

 

       Types of MIO in victims with TST and polytrauma, depending on the forecast of the nearest outcome, are presented in Table 2. From Table 2, it follows that more than half of MIO in victims with TST and polytrauma were performed in the 2nd therapeutic and tactical group of victims with a positive prognosis-68.1%, the least-in the 3rd therapeutic and tactical group of victims with an unfavorable prognosis-1.5%. In the 1st treatment and tactical group of patients with a favorable prognosis, MIO was performed in almost a third of the victims – 30.4%. Closed intramedullary osteosynthesis with rod blocking was performed in most cases in the 2nd therapeutic and tactical group of victims with a positive prognosis-71.9%, less often – in the 1st therapeutic and tactical group with a favorable prognosis (26.2%) and extremely rarely – in the 3rd therapeutic and tactical group of victims with an unfavorable prognosis (1.9%).

Table 2. Types of minimally invasive osteosynthesis in patients with severe combined trauma and polytrauma, depending on the prognosis of the nearest outcome

 

Forecast of the nearest outcome	Types of minimally invasive osteosynthesis			Total number of osteosyn-theses
	Intramedu-llary with blocking (%)	Plates with polyaxial screws with blocking (%)	Extra-focal osteosyn-thesis (%)
Group 1: favorable	54(26,2)	65(39,6)	-	119(30,4)
Group 2: positive	148(71,9)	97(59,1)	22(100)	267(68,1)
Group 3: unfavorable	4(1,9)	2(1,3)	-	6(1,5)
Итого/Total	206(100)	164(100)	22(100)	392(100)

 

     Bone osteosynthesis with plates with a blocking system, as well as closed intramedullary osteosynthesis, was performed in most cases in the 2nd therapeutic and tactical group of victims with a positive prognosis-59.1%, less often – in the 1st therapeutic and tactical group with a favorable prognosis (39.6%) and extremely rarely – in the 3rd therapeutic and tactical group of victims with an unfavorable prognosis (1.3%). KDO according to G. A. Ilizarov was performed only in the 2nd treatment and tactical group of victims with a positive prognosis-100.0%.

The results of the study allowed us to state three types of traumatic disease course in 413 examined patients with TST and polytrauma. The first type is uncomplicated TB course. According to this type, TB occurred in 274 victims, that is, in 66.3% of cases. This type of TB was typical for all the victims of the 1st treatment and tactical group with a favorable prognosis (110) and for 164 victims with polytrauma of the 2nd treatment and tactical group with a positive prognosis. The second type is a complicated course of TB with recovery. According to this type of course, TB occurred in 73 patients with severe systemic visceral and generalized complications, characterized by high labor intensity and duration of treatment. The DCO tactics were not applied to these victims, as they went beyond the time frame of the tactics. During the treatment of complications, they maintained the primary fixation of DTC fractures by ANF, enhanced by various methods, and after the complications were cured, planned surgical treatment of DTC fractures was performed according to individual programs. This period of TB was beyond the scope of the study and was not part of its tasks. The third type is a complicated course of TB with a fatal outcome. This type of TB course was observed in 66 patients with the most severe polytrauma. Depending on which group the victim belonged to, one of two treatment tactics was used. Early total care (ETC) - tactics of early full - volume trauma care or Damage control orthopedics (DCO)-tactics of programmed multi-stage surgical treatment of areas and segments of the musculoskeletal system.

Based on the types of TB course, a contingent of patients with TST and poly-injuries accompanied by DTC fractures was formed to perform minimally invasive osteosynthesis (Table 3).

Таблица 3 Формирование контингента пострадавших с ТСТ и политравмами, сопровож-давшимися переломами ДТК, для выполнения минимально инвазивного остеосинтеза.

Table 3 Formation of a contingent of victims with SСT and polytrauma, accompanied by DTC fractures, to perform minimally invasive osteosynthesis.

        

Tactics of treatment of LTB fractures	Number of victims(%)		The closest outcomes to the beginning of the tactics of treatment of LTB fractures (%)
			they died	Survived with complications	They survived without complications
Completed MIO	274 (66,3)	-		-	274(66,3)
Tactics ETC	158 (38,2)	-		-	158(38,2)
Tactics DCO	116(28,1)	-		-	116(28,1)
MIO was not performed	139(33,7)	66(16,0)		73(17,7)	-
Total	413(100,0)	66(16,0)		73(17,7)	274(66,3)

 

     Table 3 shows that minimally invasive osteosynthesis was possible in 274 patients with TST and polytrauma out of 413, which was 66.3%. MIO was not performed in 66 patients who died in the second period of TB (16.0%), and in 73 patients with severe systemic visceral and generalized infectious complications (17.7%). Among the victims who underwent M & E, ETC tactics were used in 158 victims (38.2%), and DCO tactics were used in 116 victims (28.1%). The goal of minimally invasive osteosynthesis in patients with TST and polytrauma was the need for rapid, minimally traumatic, but at the same time, sufficiently strong fixation of DTC fractures with the most accurate restoration of the anatomical structure of the damaged bones. With this approach to the surgical treatment of DTC fractures, favorable conditions were created for rapid and lasting fusion of fractures, early functional treatment and rehabilitation of victims, and achieving the highest possible level of quality of life after treatment.

Results

The immediate outcomes of treatment of 274 victims with TST and polytrauma after performing a full and final volume of surgical intervention on DTC were good both with the ETC and DCO tactics. There were no fatal outcomes. The frequency of non-severe local IO in the field of surgical intervention was 4.0% and was distributed almost evenly in all types of MI. The average period of inpatient treatment of all victims with TST and polytrauma, who used the MIO technology, was 23.8±2.3 days: with closed intramedullary osteosynthesis-19.8±0.3 days, with bone osteosynthesis-24.2±1.2 days, with KDO according to G. A. Ilizarov-27.3±1.9 days.

The long-term results of treatment were analyzed in 258 victims, since it was not possible to establish contact with 16 victims. In all 258 examined patients with TST and polytrauma, long-term treatment results were evaluated using an objective multifactorial method – the Neer-Grantham-Shelton scale. The long-term results of treatment of DTC fractures with MIO technology in all operated patients with TST and polytrauma are shown in Table 4.

 

Table 4 - Long-term results of fracture treatment

Types of minimally invasive osteosynthesis	Long-term results of fracture treatment(%)			Total victims (%)
	Хорошие	Удовлетвори-тельные	Неудовлетво-рительные
Intramedullary with blocking	128 (49,6)	27 (10,5)	-	155 (60,1)
Plates with polyaxial screws with blocking	81(31,4)	12 (4,6)	-	93 (36,0)
Extrafocal osteosynthesis	-	10 (3,9)	-	10 (3,9)
Total	209 (81,0)	49 (19,0)	-	258 (100)

 

     Table 4 shows the absence of unsatisfactory results of treatment of the victims who underwent MIO. In the vast majority of cases, the long-term results of treatment were good-81.0%, and in 19.0% - satisfactory. More good results were obtained with closed intramedullary osteosynthesis with blocking (49.6%), less – with bone osteosynthesis with plates with a blocking system (31.4%). At the same time, with closed intramedullary osteosynthesis, the proportion of good long – term treatment results was 82.6%, and with bone osteosynthesis with plates-87.1%. With extra-focal osteosynthesis, all long-term treatment results are regarded as satisfactory.

The analysis of the anatomical and functional results of treatment more specifically reflects the long-term results of treatment and differs from the results of the previous study (Table 5). It showed that the fusion of DTC fractures with complete restoration of limb length after the MIO technology occurred in the vast majority of victims with TST and polytrauma – 96.5%. At the same time, as a result of closed intramedullary osteosynthesis, this result was achieved in 100.0% of the victims, with bone – in 98.9%, and with extra – focal osteosynthesis-only in 20.0%.

 

Table 5 - Anatomical and functional results of treatment

Types of minimally invasive osteosynthesis	Anatomical and functional results of treatment(%)			Total victims (%)
	Fusion with the restoration of the length of the limb	Fusion with shortening of the limb	Formation of a false joint
Intramedullary with blocking	155 (60,1)	-	-	155 (60,1)
Plates with polyaxial screws with blocking	92 (35,6)	-	1 (0,4)	93 (36,0)
Extrafocal osteosynthesis	2 (0,8)	6 (2,3)	2 (0,8)	10 (3,9)
Total	249 (96,5)	6 (2,3)	3 (1,2)	258 (100)

 

     Thus, the immediate outcomes of treatment of victims with DTC fractures in TST and polytrauma using advanced technologies of minimally invasive osteosynthesis were good: there were no fatal outcomes, the frequency of postoperative complications was minimal-4.0%, the duration of inpatient treatment was also minimal - 23.8±2.3 days. Long-term treatment results were good in 81.0% and satisfactory in 19.9% of cases. The long-term anatomical and functional results of treatment can also be considered good: the fusion of DTC fractures with the restoration of limb length occurred in 96.5% of cases.

A comparative analysis of the anatomical and functional results of treatment of DTC fractures in patients with TST and polytrauma in the study and control groups reliably showed the best anatomical and functional results of treatment in the victims of the study group (Table 6). In the study group of victims, good results in the form of fusion of fractures with restoration of limb length were significantly more by 28.1% than in the control group. Differences in the frequency of satisfactory results in the form of fusion of fractures with shortening of the limb were not reliable. At the same time, the frequency of formation of false joints in the study group was 25.5% lower than in the control group.

Table 6 - Comparative analysis of anatomical and functional results of treatment

Anatomical and functional results of treatment	Comparative analysis groups (%)		Total(%)
	The study group	Control group
Fusion with the restoration of the length of the limb	251 (97,3)*	108 (69,2)	359 (86,7)
Fusion with shortening of the limb	5 (1,9)	7 (4,5)	12 (2,9)
Formation of a false joint	2 (0,8)	41 (26,3)*	43 (10,4)
ИТОГО/Total	258 (100)	156 (100)	414 (100)

                  *  The differences are statistically significant (p <0,05).

     A comparative analysis of the long-term results of treatment of DTC fractures in patients with TST and polytrauma in the study and control groups reliably showed the best long-term results of treatment in the victims of the study group (Table 7).

Table 7 - Comparative analysis of long-term treatment results

Long-term treatment results	Comparative analysis groups (%)		Total(%)
	The study group	Control group
Good	209 (81,0)*	70 (44,9)	279 (67,4)
Satisfactory	49 (19,0)	59 (37,8)*	108 (26,1)
Unsatisfactory	-	27 (17,3)	27 (6,5)
TOTAL	258 (100)	156 (100)	414 (100)

                  *  The differences are statistically significant (p <0,05).

    In the study group of victims, good treatment results were significantly higher by 36.1%, and satisfactory treatment results were 18.8% less than in the control group. In the study group of victims, there were no unsatisfactory treatment results, and in the control group, their specific weight was 17.3%.Thus, in the present study, in the treatment of 413 victims with TST and polytrauma in the trauma centers of the 1st level, the use of an objective methodology for choosing rational therapeutic tactics for the treatment of DTC fractures and improved technologies of minimally invasive osteosynthesis made it possible to significantly and reliably improve the immediate outcomes and long-term results of treatment of victims with TST and polytrauma.

Conclusion

The immediate outcomes and long-term results of treatment of victims with TST and polytrauma are determined by the type of course of the traumatic disease. At the same time, it should be taken into account that, firstly, the causes and frequency of AML/PON, severe infectious complications and, as a consequence, fatal outcomes are formed in the I period of TB, and are realized in its II and III periods. Secondly, the causes and frequency of persistent pathological conditions in AML / PON, non-infectious and infectious complications are directly proportional to the severity of the injuries and the severity of the condition of the victims, on the basis of which a forecast of the nearest outcome of treatment is formed and a rational tactic for the treatment of DTC fractures is chosen.In the light of these provisions, in the I (acute) period of TB, all 413 victims studied, depending on the results of an objective assessment of the severity of the injuries received according to the NISS index and the severity of the condition of the victims according to the VPH-SP scale, surgical fixation of DTC fractures is performed using two tactics: ETC or DCO.

The best results were obtained with the ETC tactic: fusion of DTC fractures with complete restoration of limb length after the MIO technology occurred in 100.0% of victims with closed intramedullary osteosynthesis and in 100.0% of victims with bone osteosynthesis with plates. With the therapeutic tactics of DCO, the fusion of DTC fractures with a complete restoration of the length of the limbs after the MIO technology occurred in 91.5% of the victims with TST and polytrauma: as a result of closed intramedullary osteosynthesis, this result was achieved in 100.0% of the victims, with bone – in 96.0%, and with extra-focal osteosynthesis-only in 20.0%. The low specific weight of fusion with complete restoration of limb length in non-focal osteosynthesis is explained by the most severe nature of DTC fractures in which it was used – these were unstable multi-fragmented, often open DTC fractures with large bone defects and extensive soft tissue injuries.One one, the results of the analysis of the immediate outcomes and long-term results of the treatment of DTC fractures using MIO technology in patients with TST and polytrauma demonstrated the high efficiency of this surgical technology, on the one hand, and the direct dependence of the treatment outcomes on the severity of the injuries received, the severity of the condition of the victims and the number of DTC fractures in one victim, on the other hand.

About the authors

Aleksandr Anatolievich Khromov

I.I.Mechnikov North-Western State Medical University

Email: Khromov_alex@mail.ru
ORCID iD: 0000-0002-8489-4202
SPIN-code: 7062-0665

Ph.D., Associate Professor of the Department of traumotology, orthopedics and military medicine

Russian Federation, Saint Petersburg, Russian Federation

Evgeniy Konstantinovich Gumanenko

St. Petersburg State Pediatric Medical University

Email: gumanenko@inbox.ru

M.D., Professor, vice-Rector for International Cooperation and Strategic Development, Head of the Department of Mobilization Training of Healthcare and Disaster Medicine

Russian Federation, Saint Petersburg, Russian Federation

Stanislav Antonovich Linnik

I.I.Mechnikov North-Western State Medical University

Author for correspondence.
Email: stanislavlinnik@mail.ru

M.D., Professor of the Department of traumotology, orthopedics and military medicine

Russian Federation, Saint Petersburg, Russian Federation

References

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