MULTI-STAGE TREATMENT OF OPENFRACTURE OF FEMUR WITH BONE, SOFT TISSUE AND FEMORAL ARTERY DEFECTS

Kopylov V.A., Valeev M.M., Biktasheva E.M.

Orenburg State Medical University, Orenburg, Russia

MULTI-STAGE TREATMENT OF OPENFRACTURE OF FEMUR WITH BONE, SOFT TISSUE AND FEMORAL ARTERY DEFECTS 

Polytrauma is often accompanied by opened fractures. High energy injuries cause the disorders in soft tissue perfusion in the opened fracture site. It increases the risk of infectious complications and disorders of fracture union [1].
Treatment of opened fractures of extremities, which are accompanied by defects of soft tissue, magistral vessels and bones, is associated with serious difficulties [2]. The problem is choice of treatment techniques – a method for defects replacement, osteosynthesis type.
Some researchers published some data concerning the good results of preventive bone plasty. The iliac crest is a material for defect replacement [3]. A lot of authors prefer muscular flaps for closing the bone defects. According to their data, primary bone plasty does not decrease the amount of complications, but increases the risk of union disorders [4]. More perspective technique is plasty for bone defects with use of free bone autografts and restoration of perfusion [5]. However long term microsurgical surgery is not indicated for polytrauma with shock.
A dilemma is the choice of treatment techniques for a patient with polytrauma with a fracture and severe soft tissue and bone defects. Primary restoration of the extremity length and replacement of a big bone and soft tissue defect can cause some infectious complications and union disorders. The choice in favor of more possible uncomplicated healing can cause a shortening and extremity deformations.
Objective – with a clinical case, to show the result of multi-stage treatment of a patient with polytrauma, open fracture of the femur III C type (R.B. Gustilo and J.T. Anderson), bone and femoral artery defect.
The study was approved by the local ethical committee of Orenburg State Medical University. The patient gave her approval for publishing the results of the study.
The patient, age of 24, female, was admitted after a road traffic accident. She was hit by a car. At the moment of admission, she was in severe shock state. The diagnosed states were the open fracture of the femur III C type (R.B. Gustilo and J.T. Anderson) (Fig. 1) with a femoral artery injury; a closed fragmented fracture of the surgical neck of the left humerus. Intensive care of shock was performed after admission. A surgical intervention was carried out within an hour. The revision identified: a soft tissue defect (the skin and subcutaneous fat) of 8 × 5 cm, a defect of the femoral artery wall (5 cm), a bone defect of the femoral bone (4.5 cm). Owing to severe condition, the femoral artery suture was made, as well as primary surgical preparation of the left hip wound, closure of the soft tissue defect with advanced flaps, external fixation of the fracture. The postsurgical hip shortening was 5 cm. The treatment was continued in the intensive care unit.

Figure 1. The patient B., age of 24. X-ray image of left femur at hospital admission


After 72 hours, closed osteosynthesis of the left hip with the locking retrograde nail was conducted without the intramedullary canal drilling. Also opened reposition and osteosynthesis of the humerus with the locking compression plate (LCP) were conducted.
The wounds healed with primary tension. The fracture union was achieved. Six months later, the staged surgical treatment was conducted for the left hip lengthening. The distraction apparatus (Ilizarov frame) was mounted without removal of the nail. The surgery was conducted: removal of the locking screws in the upper one-third of the hip, femoral bone osteotomy, Ilizarov apparatus. Two proximal rings were fixed with the nails, the distal ring – with the pins (Fig. 2). It allowed simplification of the process of distraction owing to absence of risk of declination of the femoral bone axis after lengthening the last one.

Figure 2. The patient B., age of 24. X-ray image after the second stage – installation of distraction apparatus

The normal length of the left lower extremity was achieved after 38 days (Fig. 3). The distraction frame was dismounted. The nail was locked. The patient could bear on her lower extremity and walk without a walking-stick. Ten weeks later, the organotypic rebuilding of callus happened (Fig. 4). The extremity function restored completely.

Figure 3. The patient B., age of 24. X-ray image of left femur 10 weeks after completion of distraction



Figure 4. The patient B., age of 24. X-ray image of femur 10 weeks after completion of distraction. Ilizarov apparatus has been dismounted, the nail has been blocked


CONCLUSION

The multi-staged treatment is appropriate for the severe polytrauma with the type III C opened femoral fracture, injuries to the magistral veins and a significant bone defect. It consists in primary intramedullary osteosynthesis with the hip shortening for achievement of union. After fracture union, the lengthening is possible with Ilizarov frame and without removal of the nail that allow simplifying the apparatus mounting, reducing the working incapability period and restoring the function. 

 Information on financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of clear or potential conflicts of interests relating to publishing this article.

REFERENCES:

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2.  Erickson J, Culp B, Kayiaros S, Monica J. Acute multiple flexor tendon injury and carpal tunnel syndrome after open distal radius fracture. Am J Orthop (Belle Mead NJ). 2015; 44(11): 458-460
3.  Kobbe P, Frink M, Oberbeck R, Tarkin IS, Tzioupis C, Nast-Kolb D et al. Treatment strategies for gunshot wounds of the extremities. Unfallchirurg. 2008; 111(4): 247-254
4.  Hutson JJ Jr, Dayicioglu D, Oeltjen JC, Panthaki ZJ, Armstrong MB. The treatment of Gustilo grade IIIB tibia fractures with application of antibiotic spacer, flap, and sequential distraction osteogenesis. Ann Plast Surg. 2010; 64(5): 541-552
5.  Dazhin AYu, Minasov BSh, Valeev MM, Chistichenko SA, Biktasheva EM. Free osteoplasty using a vascularized fibular fragment for treatment of patients with extensive segmental defects of forearm bones. Genius of Orthopedics. 2013; (2): 58-61. Russian (Дажин А.Ю., Минасов Б.Ш., Валеев М.М., Чистиченко С.А., Бикташева Э.М. Свободная костная пластика васкуляризированным фрагментом малоберцовой кости при лечении больных с обширными сегментарными дефектами костей предплечья //Гений ортопедии. 2013. № 2. С. 58-61)

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