THE CASE OF SUCCESSFUL TREATMENT OF A PATIENT WITH THE CONSEQUENCES OF POLYTRAUMA COMPLICATED BY PURULENT INFECTION

Klyushin N.M., Mikhaylov A.G., Shastov A.L., Mukhtyaev S.V., Gayuk V.D.

Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics, Kurgan, Russia

 THE CASE OF SUCCESSFUL TREATMENT OF A PATIENT WITH THE CONSEQUENCES OF POLYTRAUMA COMPLICATED BY PURULENT INFECTION

The problem of prevention and treatment of infectious complications in patients with multiple and associated injuries, which are highly common in patients with the mechanic injury, is still actual [1-5].
The rate of purulent complications in such patients is significantly higher, and the course is more severe in comparison with single fractures. It is determined by some well-known causes: shock, blood loss, decrease in host defenses, pattern of microbial flora and others [5-8].
The modern approach to restorative treatment of patients with polytrauma and purulent infection supposes the complexity, strict individuality and continuity of medical process. The therapeutic measures are to be directed to main links of the symptomatic complex of a disease and, first of all, to suppression of the purulent process, recovery of supporting ability and skeletal function, and to early rehabilitation [9, 10].
A type and volume of therapeutic techniques and their consequences are determined by clinical picture of a disease in each case [11].
Objective – to present a clinical case of complex stage surgical treatment and rehabilitation of a patient with polytrauma, accompanied by neurologic and purulent-inflammatory complications.
The study corresponds to the ethical standards and the norms of the Russian Federation legislation. The patient gave his written consent for participation and data publishing.
The history of the disease. The patient suffered from the associated injury in a road traffic accident: a closed thoracic injury with hemothorax, compression and fragmented fractures of Th12-L1, spinal cord compression, a left-sided trimalleolar fracture with complete dislocation of the foot, a closed bimalleolar fracture to the left. Shock of degree 2. Anti-shock therapy, conservative treatment of fractures with skeletal traction from both calcaneal bones and the extension brace. Some bedsores appeared in the calcaneal and sacral regions. The patient refused from surgical management (transpedicular fixation and leg osteosynthesis) according to place of residence.
Three months after the injury, the patient was admitted to the purulent osteology clinic of Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics. The diagnosis was: “Traumatic  disease of the spinal cord in subacute period. Th12-L1 compression-comminuted fractures with spinal cord compression. Disordered functioning of pelvic organs. Lower rough flaccid paraparesis (with plegia in the feet). ASIA-A. Chronic posttraumatic osteomyelitis of both ankle joints, the fistulous type. Pseudoarthrosis of distal parts of the bones of both legs. Left lower extremity shortening (2 cm). A bedsore in the sacral region. Purulent wounds in both ankle joints.
Local status at admission: passive prone position. A bedsore in the sacrum (6 × 8 cm), with necrosis in the center, slow granulation, bordering epithelialization, unsmooth borders with scarry transformation. Also there were slow granulating superficial wounds in the calcaneal region and in both ankle joints (from 2 × 2 cm to 3 × 4 cm). The movements in knee joints: D = S 80/170°. No movements in ankle joints. Soft tissue hypotrophy in both legs. Relative shortening of the left lower extremity (2 cm). Left foot valgus deformation.
Neurological status at admission: no knee or ankle reflexes on both sides. Leg strength: hip D = S 3-3.5 points, leg D = S 0-1, left foot – 1 point, right foot – 0 points. The muscular sense is weak in distal parts of the lower extremities. Kyphotic deformation in the thoracolumbar spine. Bilateral hypesthesia along L3-L4 dermatomes. Urination with catheter, adequate volume. Intestinal habits of delay type.
Two-view X-ray images of the right leg and the foot showed some signs of non-united fractures of the lower one-third of the fibular bone with displacement at an angle and along the width. Pseudoarthrosis of internal malleolus and the calcaneal bone through the tuberosity, foot dislocation outwards. Two-view X-ray images of the left leg and the foot showed some signs of non-united fractures of internal and external malleolus, anterior border of the tibial bone, the lower one-third of the fibular bone and the calcaneal bone, a compression fracture of ankle bone, foot antedislocation.
MSCT and MRI of the thoracolumbar spine showed a compression-comminuted (burst) fracture of L1 vertebra with longitudinal compression of the medullary cone. Th12-L1 traumatic hernia. Th12 compression fracture with compression of degree 1.
The laboratory data at admission: clinical blood analysis – ESR 35 mm/h, leukocytes 5.2*109/l, no signs of arrhythmia; clinical urine analysis and biochemical blood analysis showed the insignificant declination; bacteriological examination of the left leg wounds identified the growth of Pseudomonas aeruginosa 10*3 CFU/ml, the right leg wounds – Staphylococcus epidermidis (MRSE) 10*5 CFU/ml, the sacrum wound – P. Aeruginosa 10*7 CFU/ml.
At the first stage of treatment, it was decided to stop the purulent process and to achieve healing of the wounds. Necrectomy of bedsores and ultrasonic preparation, plastic surgery for the sacrum with use of local tissues and for the feet wounds with use of right hip split flap were carried out. Antibacterial and anticoagulant therapy was conducted. In the postsurgical period, the borders of the wounds were adapted. The sutures were consistent and were removed on the day 14. The wounds healed with primary tension.
Serous discharge appeared after partial removal of the sutures on the wounds of the sacrum and the left leg. The dressings were ineffective within a week. Enterococcus faecalis (10*3 CFU/ml) was identified in the sacrum wound. Therefore, 4 weeks after the first surgery, recurrent necrectomy with ultrasonic cavitation of the wound, and application of secondary sutures were conducted (Fig. 1). After 15 days, the wounds healed with secondary tension, and the sutures were removed. Dihescence was not identified. The pyoinflammatory process was eliminated.

Figure 1. The condition of soft tissues on the legs and sacrum before and after the first stage of treatment



Thenext stage was spinal stabilizing surgery for vertical positioning the patient and prevention of hypostatic complications and recurrent bedsores. One month after correction of purulent infection foci, L1 laminectomy, partial resection of Th12 and L2 arcs, spinal cord anterior decompression, spinal canal reconstruction, meningoradikulolyse, L1 vertebral corpectomy, Th11-Th12-L2-L3 spondylosynthesis with Stryker transpedicular fixation system, Th12-L2 corporodesis with MASH-cage were performed. The postsurgical period was without complications. The drain was removed on 7th day. The wound healed with primary tension. The sutures were removed on 15th day (Fig. 2). After the surgery, the patient noted the psychological discomfort, increasing activity. The care became simpler. Defecation and urination were controlled.

Figure 2. CT scan and X-rays of the spinal column before and after the second stage of treatment, the appearance of postoperative wounds on the back

The third stage of treatment was conducted after one and a half of the month. The surgery was conducted: necrectomy, ankle joint revision, arthrodesis of left and right ankle joints with Ilizarov device (Fig. 3). The postsurgical wounds healed with primary tension. The sutures were removed on the 16th day. After the surgery, the patient received remedial gymnastics course with participation of the instructor. The control laboratory values were without significant declinations. The increase in abnormal microflora was not identified. Fixation in Ilizarov device was stable.

Figure 3. X-rays of the ankles before and after the third stage of treatment

At the moment of hospital discharge, the patient could sit in the bed and move with the walking frame (Fig. 4). Tendon reflexes from the lower extremities: knee D – abs, S – response. Movements in hip joints with muscular strength of 3-4 points on both sides. Movements in knee joints with muscular strength: 3.5-4 to the left, 3-3.5 to the right. Paresthesia along Th12 and L1dermatomes. Hypesthesia from L2 to S2 dermatomes. Anesthesia of S3-S5 dermatomes on both sides. Urination with straining. Regular defecation. The hospital treatment duration was 128 days.

Figure 4. Appearance of the patient after the third stage of treatment

In the period fixation for achievement of union, the patient was observed by the traumatologist-orthopedist in the outpatient settings with monthly X-ray control. Five months later, the patient was admitted for Ilizarov device dismounting and the course of neurorehabilitation with remedial gymnastics.
At admission, the general condition was satisfactory, with ability to self-care. The body temperature was within the normal values. The skin and visible mucosa were of physiological color, without spots. No edema. Lymph nodes were not enlarged. Hemodynamics was stable. Breathing was tidal and vesicular, without stertor. Cardiac tones were clear and rhythmical, with rate of 70 beats per minute. The abdomen was soft and painless. Defecation was regular. Urination was free and independent. Diuresis was adequate to water load. The patient moved with crutches with supporting to both lower extremities over the long distance. Moderate kyphotic deformation in the thoracolumbar spine. Fixation with Ilizarov device for both legs and the feet was stable. The fixation period was 140 days, without inflammation around the pins, with normal scars of the postsurgical wounds. The patient was alert, could communicate. He was well-oriented in space and time, with adequate behavior. The pupils D = S, normal photo response, no nystagmus. The movements of the pupils were within the full range. The palpebral fissures D = S, nasolabial folds D = S. The tongue was along the middle line, without deviation. No dysarthria and aphasia. Romberg's position was normal. The finger-to-nose test was normal. No meningeal signs. Normal abdominal reflexes. Reflexes from the lower extremities: knee D = S – weak, ankle D = S abs. Lower extremity strength: hip D = S 4 points, leg D = S 3 points, left foot 1, right foot 1. Leg hypotrophy. Weak kinesthesis in distal parts. Bilateral L3-L5 hypesthesia.
The X-ray images of the ankle joints showed some signs of ankylosis. Ilizarov device was used.
The first stage of the treatment included the surgical intervention: two-level puncture implantation of temporary epidural electrodes at the lower thoracic and lumbar levels under radiologic and neurovisual control; Ilizarov devices dismounting on both legs and on the feet.
Inhospital treatment was carried out that included Actovegin, vasodilating, angioprotecting, antihypoxant and nootropic agents, B vitamins, remedial gymnastics, electrostimulation with electrodes (20 minutes, 2 times per day within 10 days). On the 13th day, the patient was discharged from the hospital for outpatient observation. His condition was satisfactory.
One year later, the control examination showed the positive trends: hip muscle strength increase up to 5 points, legs – 4 points. There were not any recurrent pyoinflammatory processes. The patient could wear usual shoes without secondary measures with supporting to both lower extremities (Fig. 5). The intensity of sensitive disorders in the lower extremities decreased. The X-ray images of the ankle joints showed some signs of ankylosis. Thoracolumbar X-ray images showed the stable fixation (Fig. 6). The result was estimated as good. The patient continued his professional activity.

Figure 5. Appearance of the patient 1 year after treatment



Figure 6. X-rays after 1 year of treatment

 

CONCLUSION

The good functional outcome of the treatment was achieved with the chosen techniques of multi-stage treatment with correction of chronic infection foci, spinal stabilizing surgery and reconstructive surgery for both lower extremities with further course of neurorehabilitation. 

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:

1.  Traumatology: national guidelines. Kotelnikov GP, Mironov SP, editors. Moscow: GEOTAR-Media Publ., 2011. 1104 p. Russian (Травматология: национальное руководство /под ред. Г.П. Котельникова, С.П. Миронова. 2-е изд., перераб. и доп. М.: ГЭОТАР-Медиа, 2011. 1104 с.)
2.  Lyulin SV, Meshcheriagina IA, Samusenko DV, Stefanovich SS. The tactics of traumatic disease treatment in patients with polytrauma at the resuscitation stage. Genius o Ortopedcsi. 2015; (3): 31-37. Russian (Люлин С.В., Мещерягина И.А., Самусенко Д.В., Стефанович С.С. Тактика лечения травматической болезни у пациентов с политравмой на реанимационном этапе //Гений ортопедии. 2015. № 3. С. 31-37)
3.  Agadzhanyan VV, Yakushin OA, Shatalin AV, Novokshonov AV. Significance of early interhospital transportation in complex treatment of patients with acute spine and spinal cord injury. Polytrauma. 2015; (2): 14-20. Russian (Агаджанян В.В., Якушин О.А., Шаталин А.В., Новокшонов А.В. Значение ранней межгоспитальной транспортировки в комплексном лечении пострадавших с позвоночно-спиномозговой травмой в остром периоде //Политравма. 2015. № 2. С. 14-20)
4.  Leonchuk DS, Sazonova NV, Shiriaeva EV, Kliushin NM. Chronic posttraumatic osteomyelitis of the humerus: economic aspects of treatment with the method of transosseous osteosynthesis method using the Ilizarov fixator. Genius of Ortopedics. 2017; (1): 74-79. Russian (Леончук Д.С., Сазонова Н.В., Ширяева Е.В., Клюшин Н.М. Хронический посттравматический остеомиелит плеча: экономическиеаспекты лечения методом чрескостного остеосинтеза аппаратом Илизарова //Гений ортопедии. 2017. № 1. С. 74-79)
5.  Agalaryan AKh, Ustyantsev DD. Use of local negative pressure technique (vacuum therapy) in treatment of purulent wounds in patient with polytrauma. Polytrauma. 2014; (1): 50-55. Russian (Агаларян А.Х., Устьянцев Д.Д. Применение метода локального отрицательного давления (вакуум-терапии) в лечении гнойных ран у пациентки с политравмой //Политравма. 2014. № 1. С. 50-55)
6.  Agadzhanyan VV. Septic complications in polytrauma. Polytrauma. 2006; (1): 9-17. Russian (Агаджанян В.В. Септические осложнения при политравме //Политравма. 2006. № 1. С. 9-17)
7.  Stoyko YuM, Mazaeva BA. Staged reconstructive treatment of extensive bedsorе of sacral-coccygeal spine in a patient with osteomyelitis and diabetes. Wounds and wound infections. 2015; 2(4): 52-55. Russian (Стойко Ю.М., Мазаева Б.А. Поэтапное реконструктивно-пластическое лечение обширного пролежня крестцово-копчикового отдела позвоночника у больных с остеомиелитом и сахарным диабетом //Раны и раневые инфекции. 2015. Т. 2, № 4. С. 52-55)
8.  Bondarenko AV, Gerasimova OA, Lukyanov VV, Timofeev VV, Kruglykhin IV. Composition, structure of injuries, mortality and features of rendering assistance for patients during treatment of polytrauma. Polytrauma. 2014; (1): 15-21. Russian (Бондаренко А.В., Герасимова О.А., Лукьянов В.В., Тимофеев В.В., Круглыхин И.В. Состав, структура повреждений, летальность и особенности оказания помощи у пострадавших на этапах лечения политравмы //Политравма. 2014. № 1. С. 15-21)
9.  Shpachenko NN, Salem Abdallakh All Shobaky, Zolotukhin SE, Dankina IA. Shin fractutes operative treatment efficiency in dependence on time of operation and condition of polytraumatized patient. Ukrainian Journal of Clinical and Laboratory Medicine. 2013; 8(4): 204-209
10. Dulaev AK, Manukovsky VA, Alikov ZYu, Goranchuk DV, Dulaeva NM, Abukov DN et al. Diagnosis and surgical treatment of adverse consequences of spinal trauma. Spine Surgery. 2014; (1): 71-77. Russian (Дулаев А.К., Мануковский В.А., Аликов З.Ю., Горанчук Д.В., Дулаева Н.М., Абуков Д.Н. и др. Диагностика и хирургическое лечение неблагоприятных последствий позвоночно-спинномозговой травмы //Хирургия позвоночника. 2014. № 1. С. 71-77)
11. Brunel AS, Lamy B, Cyteval C, Perrochia H, Téot L, Masson R et al. Diagnosing pelvic osteomyelitis beneath pressure ulcers in spinal cord injured patients: a prospective study. Clinical Microbiology and Infection. 2016; 22(3): 267.e1-267.e8

Статистика просмотров

Загрузка метрик ...

Ссылки

  • На текущий момент ссылки отсутствуют.