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ГСНРШ Opmomáim № 2 1997 г.
© В.К. Кельман, С.Е. Шафит, 1997.
Использование системы оценки тяжести повреждения >7 при сохранении конечностей в случаях раздробленных переломов
со сдавлением мягких тканей
В.К. Кельман, С.Е. Шафит
Traumatology and Orthopaedics Research Institute, Russia, Nizhny Novgorod, Director - professor V.V. Azolov
Травмы со сдавлением (пять конечностей у четырех пациентов) при наличии обширных разрывов и нежизнеспособных участков кожи, подкожной ткани, фасций и мышц, отделении надкостницы, обнажении кости и массивном загрязнении по системе оценки тяжести повреждения конечности >7 лечили в период с 1980 по 1992 гг., комбинируя неоднократные хирургические обработки ран, метод Илизарова и постепенное закрытие раны. Травма по Gustilo III степени Типа В отмечалась в четырех случаях, травма III степени Типа С - в одном случае. Отдаленные результаты от трех до пятнадцати лет. Продолжительность госпитализации варьировала от 86 до 247 дней. Общая продолжительность лечения составляла от 9-ти до 38 месяцев. Результат сращения кости был отличным в трех случаях и удовлетворительным в одном случае. Функциональный результат был отличным в одном случае и удовлетворительным в трех случаях. Все пациенты возобновили свою прежнюю деятельность, все работают, за исключением одной пациентки (она уволилась еще до травмы) и удовлетворены лечением. Метод Илизарова является методом выбора при тяжелых раздробленных переломах со сдавлением мягких тканей, он дает возможность сохранять конечности, которые прежде подвергались ампутации.
Ключевые слова: травмы с синдромом сдавления, оскольчатые травмы, рубленые поражения, балльная оценка, метод Илизарова, клинический результат, функциональный результат, контроль, сохранность конечности, больной, метод выбора.
Injuries that mangle or crush an extremity are devastating and has always been a challenge to orthopedic surgeons. The possibilities of multiple operations, medical and psychological disability, and protracted rehabilitation loom from one side and primary amputation from another are before these patients. Mangled Extremity Severity Score (MESS) is a rating scale for lower extremity trauma, based on skeletal/soft tissue damage, limb ischemia, shock, and age8 (Tab. I). In these authors,
MESS value > 7 predicted amputation with 100% accuracy. Ilizarov technique is designed specifically for the cases with loss of bone, leg-length discrepancy, comminuted fractures with severe tissue loss6,7. We have an experience of successful treatment of four patients with MESS score 8-9 by combination of successive debridements, Ilizarov fixation and gradual skin covering as a leading elements of the management.
MATERIALS AND METHODS
From 1980 through 1992 four tibia open-fracture patients (three males and one female) with MESS score >7, estimated retrospectively (case one, four) and prospectively (case two and three) were seen and treated in Nizhniy Novgorod Trau-matology and Orthopedics Research Institute with adequate follow-up. Fractures were obliquetransverse (case one and four), butterfly (case three), transverse (case two). Four limbs were Gustilo III B Type, one - III C. Patients charts and X-rays were reviewed and patients were followed from three to fifteen yrs. Details of wounds and fracture healing and all complications were recorded (Tab. II). In one patient both limbs were injured, MESS score was 6 and 8 in right and left shin respectively. Motorcycle accident, pressing by bulldozer blunt blade, 500-kg metal part drop, running over the leg of bus were causes of injury. All were crushed with extensive laceration and devitali-zation of skin, subcutaneous tissue, fascia and mus-
cles, with periosteal stripping, bone exposure and massive contamination. Three patients had been managed initially elsewhere (cases one, two and three), one (case four) was admitted in our institution in thirty five min after the accident. Before hospitalization in our institution autovenous grafting of damaged popliteal artery in one patient (case two) was performed. In another two cases (case one and three) only debridement were accomplished. In these three cases all wounds were sutured. In our opinion, inadequate debridement and suturing considerably worsen patients status and contributed to quick development of severe wound infection and sepsis (in cases one and three). In case one and three skeletal traction by calcaneus were applied, in case two - plaster cast immobilization. After deterioration of general condition of these three patients they were admitted at the Institute in two-three days after injury (Tab. III). Just after admittance all patients were operated. In cases one, two and three
wounds had features of purulent complications, such as swelling, edema, purulent wound discharge with a sour odor, cinereous muscles, multiple necrosis of tendons, fascia and fatty tissues. Incase two crepitation was revealed. In case four massive crush injury in patient of eighty two yrs did not allow to perform amputation just in admittance. The first priority for this patient's treatment was the efficient and aggressive resuscitation. Debridement and Ilizarov fixation in this case we considered at first as life-saving procedure less dangerous than femur amputation. Tibialis anterior artery injury was discovered in case one and three. In case one it led to ischemia and eventually lost of distal part of foot and toes. When we discovered this injury from the trauma passed two days and attempts to restore the vessel was futile and dangerous. In case three it was a lot of necrotic tissue and tissues with doubt viability near the vessel, defect was of ten sm. and above the defect thrombosis of artery spreading in popliteal artery was revealed. Ischemic disorders were not so serious, and restoration of the artery was not also performed. All patients were managed with repeated every one-three days excision on necrotic tissues, liizarov fixation, continuing closing of wounds by traction, split skin grafting. In case four with circular skin detachment cutting off the detached skin and perforated split skin grafting (by the graft taking from this futile flap) was accomplished. Intraosseous perfusion by Reopoliglucini 400 ml, S. Novocaini 0,25%-400 ml, Penicillini 10.000.000 U in 500 ml S. Natrii chl., 0,9%-500 ml
were performed during debridements. In case four to this mixture Pseudomonas and Staphilococcus bacteriophage (25 ml) were added. Most part of this mixture pour through the wound. In case I five hypervolemic hemodilution procedures (Pentamin, Polides, Reopoliglucin, Hemodes) for improving microcirculation were performed. Wound closure carried out gradually. Debridements were followed by open packing in all cases. Approximation sutures (case one and two), or wires conducting through wound edges (case two) for there traction and der-matotension (case one and two), split skin grafting (case one, three and four), suturing with irrigation drainage when it was possible were done. Plaster cast immobilization for three- four weeks after fixator removing was applied. Partial limb loading began on 247, thirty second, thirtieth and twenty first days from trauma in first, second, third and fourth cases respectively. In all cases antibiotics were given. Infection occurred in all cases. In case three on ninety first day after trauma tibia osteo-clasia was done and on twelfth day after this bone transport began for bifocal osteosynthesis (0.25 mm four times per day). In case of wire track infection (case one) fixator was removed two times, plaster cast was applied before subsiding of inflammation. Prolonged fixation in this case was made on 223 day after trauma.
The duration of hospitalization ranged from eighty six to 247 days. The total duration of treatment ranged from nine to thirty eight months.
RESULTS
Duration of follow up was from three to fifteen years. The results were divided into bone results and functional results, according to the classification of the Association for the Study and Application of the Method of Ilizarov1,3 and as described by G. K. Dendrinos et al.4 Consolidation was achieved eventually in all cases (Tab. IV). Bone result was excellent in cases two, three and four; fair (axial deformation, leg-length inequality, compensatory equinus 30°) in case one. At the beginning the parents of this boy (case one) refused from bifocal lengthening, then he himself was reluctant to continue a long treatment. Shortening was compensated by special insole two sm. height, about five years after trauma he walked with cane. Functional result
was fair in case one, three and four (limp, ankle rigidity, pain were observed in this patients; in case three also soft-tissue sympathetic dystrophy, venous insufficiency and in case four stiffness if knee joint occurred). Excellent result was in case two. All patients returned to previous activity, patient in case one graduated from the University, was married, all but case four (she was retied before trauma) have a job. In case four additional fixator applying was necessary in thirty nine months after trauma for equinus correction. It would be possible to correct it early, but the patient insisted on removing of the wires which were conducted through foot. All patients were satisfied by the treatment.
COMPLICATIONS
Four patients had a total ten complications. Sepsis occurred in case one and three in admittance. It resolved to seventh day after trauma. Signs of infection arose around some wires in two patients. In case one wire track infection appeared on eleventh day after applying Ilizarov fixator. Conservative
attempts to abort the process were futile and fixator was removed and reapplied. The process relapsed and on sixty third day after the trauma fixator was removed again. Immobilization by plaster cast was accomplished before 223 day after the trauma, when Ilizarov fixator was applied in the third time.
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On the 357th day after trauma reconducting of two wires instead of infected was performed because wire track infection appeared once again. In case three this infection developed to the time of removing fixator (total time affixation in this case was 575 days, bifocal lengthening of the ten sm. defect was accomplished). Transplant lysis after split skin grafting occurred in case one on the twenty eighth day after trauma (30%) and in case four on the fourth day after trauma (40%). Regenerate fracture sustained in case one in ninety seven days after
removing of fixator. About in a month after the refracture fixator was reapplied for 248 days. It was the last operation of fixator applying in this case. Eczema occurred in case four in about five months after the trauma and fully subsided only after fixator removing. All patients had severe pain after the trauma and needed analgesics and medication for sleep. Two-three days after operations they were prescribed narcotic analgesics, then occasional analgesics (pirazolone derivates).
DISCUSSION
G. V. Poole et al.9 reviewed their experience with forty eight mangled lower extremities in forty six patients. Twenty-one penetrating wounds and twenty five blunt injuries occurred in thirty seven men and nine women. Severity of injuries to muscle, skin, and major nerves were strongly interrelated, but there were no correlation between injuries to these tissues and severity of bone injury. Twenty-four limbs were salvaged, and twenty four were amputated. Increased severity of soft tissue injury was associated with a greater probability of limb loss, but limb salvage or amputation could not be predicted in these authors, accurately by any variable or group of variables such as age, mechanism of injury. Injury Severity Score, presence of shock, level of injury, venous injury or repair, sequence of repair (vascular vs. skeletal), time of fasciotomy, arteriography, blood requirement, or duration of ischemia. Amputation was best predicted by severity of injury to the sciatic or tibial nerves (P < 0.001), and by failure of arterial repair (P < 0.01). Primary amputations, in our opinion, should be performed only in cases of motor and sensory loss with ischemia >8 h, absence of capillary refill, when trial of arterial and venous repair is futile and may be dangerous due to possible renal failure and in devastating bone and soft tissue lost. F. Bonanni et al.2 described fifty-eight lower limb salvage attempts over a ten-year period. Injuries were retrospectively scored using the Mangled Extremity Syndrome Index (MESI), Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), and the Limb Salvage Index (LSI). Cross-validational sensitivity and specificity analyses revealed no predictive utility in any of the four indices. They conclude that efforts must be directed at more precisely determining the factors that aid in the decisions to terminate futile salvage efforts. But primary amputations were excluded in this study.
Ilizarov technique is done in an attempt to solve the problem of non-union, deformity, leg-length discrepancy, joint stiffness, soft-tissue atrophy and disuse osteoporosis. The method is also useful in comminuted fractures with massive soft tissue damage especially when purulent complications occur.
In all four patients with MESS>7 consolidation had been successfully obtained and weight bearing restored. An excellent bone result was in three patients, and functional results seemed to be inferior: in three patients they were fair. However this series included most severe trauma. Condition of muscles, vessels, joints, nerves severe purulent complications due to inadequate debridement just after the trauma affected the functional result in most degree, than bone damage. Even extensive loss of muscles if debrided good, may allow to leave enough muscle to provide adequate function. Injury of vessels if there are not features of irreversible ischemia such as cool, paralyzed, insensate limb is not also an indication for amputation. In our opinion nerve injury, including tibial nerve, especially neurapraxia is not an indication for amputation too. In case of wire track infection, or any other local inflammatory complication when the fixator interfere with its treatment, it is possible to remove the fixator. Immobilization continued by plaster cast. After subsiding of acute inflammation fixator can be reapplied. We did not consider also a refracture as an indication for amputation. Restitution of weight bear ability in case one, when it was necessary to apply successive Ilizarov fixator three times, third fixation continued 508 days, after its removing refracture occurred and only after additional fourth fixation for 248 days stable consolidation came, confirms this opinion. These patients were not able to walk and bear weight immediately after the application of the fixator, because of extensivtf injury of soft tissues and severe purulent infection. While infection subsided and wounds healed the patients begin to bear the leg. It is worth mention about one more imperfection of MESS scoring scale. We observed a 9 year old patient with multiple trauma and severe glomerulonephritis with proteinuria till 6,2%. This patient was admitted with shock, but his BP was 150 and 80 mm Hg due to skull trauma and accompanying disease. He had degloving shin injury Gustilo IIIB with extensive laceration and devitali-zation of subcutaneous tissue, fascia and muscles, with periosteal stripping, comminuted bone exposure and massive contamination. MESS score was
of 6, despite general condition and local damages was more severe then in cases were described above. Appropriate tactic allow to rescue the limb in this case too.
Combination of repeated debridements, Ilizarov technique, gradually performed wound coverage is a method of choice in severe comminuted, crush or mangled injuries and allows to save limbs consid-
ered formerly as hopeless and subjected to amputation. MESS scoring system does not allow to predict exactly indications to amputation when this technique is used and should to be revalued. This makes necessary further search for elaborating of scoring system for predicting the possibility of limb salvage.
REFERENCES
1. Association for the Study and Application of the Method of Ilizarov Group: Nonunion of the femur. In Operative Principles of Ilizarov Fracture Treatment, Nonunion, Osteomyelitis, Lengthening, Deformity Correction, pp. 245-262. Edited by A. B. Maiocchi and J. Aronson. Baltimore, Williams and Wilkins, 1991.
2. Bonanni F., Rhodes M., Lucke J. F. The futility of predictive scoring of mangled lower extremities. J-Trauma 1993; 34(l): 99-104.
3. Catagni M., and Villa A. Nonunion of the leg (tibia). In Operative Principles of Ilizarov Fracture Treatment, Nonunion, Osteomyelitis, Lengthening, Deformity Correction, pp. 199-214. Edited by A.B. Maiocchi and J. Aronson. Baltimore, Williams and Wilkins, 1991.
4. Dendrinos G.K., Kontos S., and Lyritsis E. Use of the Ilizarov Technique for treatment of non-union of the tibia associated with infection. J. Bone and Joint Surg 1995; 77-A: 835-46.
5. Gustilo R.B., Mendoza R.M., and Williams D.N. Problems in the Management of Type III (Severe) Open Fractures: A New Classification of Type Ill Open Fractures. J. Trauma 1984; 24(8): 742-46.
6. Ilizarov G.A., Barabash A.P., and Larionov A.A. Experimental-clinical approbation of a procedure of substituting extensive defects of the long tubular bones. Orthop. Traumatol. Protez 1983; 4: 6-9.
7. Ilizarov G.A., Kaplunov A.G., Degtiarev V.E. and Ledvaev V.I. [Therapy of pseudoarthroses and ununited fractures aggravated by purulent infection by the method of compression-distraction osteosynthesis.] Orthop. Traumatol. Protez 1972; 11: 10-14.
8. Johansen K, Daines M, Howey Th, et al. Objective criteria accurately predict amputation following lower extremity trauma. J. Trauma 1990; 30(5): 568-73.
9. Poole G.V., Agnew S.G., Griswold J.A., Rhodes R.S. The mangled lower extremity: can salvage be predicted? Arn-Surg 1994, 60(l): 50-5.
Table I
Mangled Extremity Severity Score8
MESS POINTS
A. Skeletal/soft tissue injury
Low energy (stab, simple fracture; «civilian» gun shot wounds) 1
Medium energy (Open or multiple FXS, dislocation) 2
High energy (Close-range shot-gun or "military"gun shot wounds, crush injury) 3
Very high energy (above+gross contamination, soft-tissue avulsion 4
B. Limb ischemia
Pulse reduced or absent but perfusion normal 1*
Pulseless, paresthesias, diminished capillary refill 2*
Cool, perelyzed, insensate, numb 3*
*- score doubled for ischemia > 6 h
C. Shock
Systolic BP always > 90 mm Hg 0
Hypotension transiently 1
Persistent hypotension 2
D. Age (Yrs)
<30 0
30-50 1
>50 2
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Table II
Details of trauma and healing of wounds and fractures
Case 1 2 3 4
Sex, Age m, 15 m, 21 m, 40 f, 82
Mechanism of Rode on motorcycle, Pressed by blunt of bulldozer to Metal part weighting Limb was run over
Trauma collided with the car tractor 55 kg dropped on the by bus wheel
leg, and stayed on it
about 20 min.
Time from Trauma 2 days 2 days 3 days 35 min
to Hospitalization at the Institute
Time from Trauma 38 9 25 14
to Consolidation
(Mos)
Duration of Hospi- 246 86 149 247
talization
Number of Previous 1 1 1 1 0
Operations
Total Number of 11 4 3 7 5
Operations
Limb right right left right left
Localization middle third upper third upper third middle-lower third middel third
Fracture of Fibula lower third upper third upper third middel-lower third middel third
Hypotension <90 - - - + +
mm Hg
Muscle Crushing Exten. Dig. Lon., Gastrocs., Gastrocs., Exten. Dig. Lon., Exten. Dig.lon.,
exten.halluc.lon, tib. soleus, tib. soleus, tib. exten. Halluc. Lon, tib. exten. Halluc. Lon,
Ant., gastroc., soleus, Post., flex. Post., flex. Ant., peron tert., tib. Ant., peron tert.,
tib. Post., flex. Halluc. Halluc. Long., Hallucs. Long., peron. Long., peron. peron.long., peron
Long muscles peroneus longus, brevis muscles peroneus longus, brevis muscles Brev. muscles brev., gastrocs., soleus, tib. Post., flex. Halluc. Long., muscles
Wound Size 35*25 sm, 8*10 sm 25 sm**' 25sm** Almost Circular Detachment Almost Circular Detachment***
Afterial Injury a. tibialis ant - a. poplitea a. tibialis ant -
Pulse on Foot Absent + Reduced Reduced Reduced
Sensitivity Dissociation Normal Dissociation Absence Dissociation
Nerve damage* Deep+sup. peron .nerve - Deep+sup.peron Deep+sup.peron.nerve Deep+sup. peron .ner
s .nerves s ves
Limb Ischemia Distal Phalanx of I-V Toes, Back of the Foot - - - -
Organism Grown on S.epidermidis, Pseu- S.aureus, Ac- S.aureus, Ac- Corinobacterium Proteus mirabilis
Culture domonas, E.coli, Proteus mirabilis tinomycetaceae tinomycetaceae ulcerans, Neisseria perflava, Klebsiella ozaenae, Peptococcus anaerobicus
Duration of Antibi- 13 14 9 21
otic Treatment
(Days)
Gustilo Type IIIB IIIB IIIC**** IIIB IIIB
MESS Score
A 4 4 4 4 4
B 2*2 1*2 2*2 1*2 2
C 0 0 0 2 0
D 0 0 0 1 2
TOTAL 8 6 8 9 8
*- neurapraxia
** - aproximation sutures
*** - posterior flap survived (wide 8 cm.)
**** - autovenous grafting of popliteal artery was performed in 7 hours
Table III
Protocol of Operative Treatment and Postoperative Course
Case No of Time Operations Drainage/ Duration of Partial Limb Complica-
Opera- from Traum Suturing Fixation by Ilizarov Loading (from tions
tion a to Operation (days) Device Trauma/fro m Operation)
1 2 3 4 5 6 7 8
1 1 2 Wounds are connected through defect in middle third of shin; excised muscles, tendons, fascia, fatty tissues necrosis; Ilizarov fixation Open packing 31 Sepsis till 7th day; wire track infection
2 4 Excised muscles, tendons, fascia, fatty tissues, skin necrosis Open packing, gradual approximation of wound edges
3 6 Excised muscles, tendons, fascia, fatty tissues, skin necrosis Irrigating tubes
4 11 Removed 1 wire
5 24 Split skin grafting 100 sm2 Lysis of 40% transplant
6 33 2 sm. Of distal fragment were resected in transverse direction, 8 sm. - tangential (back and anterior-external wall), necrectomy on the back of the foot Irrigating tubes/Approxi mati on sutures 30 Wire track infection
7 137 Sequesters were removed, tangential anterior bone defect 10 sm., sinus track of the shin upper third revision, back foot necrectomy, amputation of I-III toes, distal phalanx of V toe, resection of I metatarsus head Irrigation-suction drainage/Suturing
8 223 Resection of metatarsus, split skin grafting on foot wound; 4 shin frames and 1 foot for equinus correction Irrigating tubes/ Suturing 508* 247/24 Wire track infection
9 357 Reconducting of 2 wires instead of infected Regenerate fracture (from trauma 828 days from removal of fixation 97 days)
10 867 Ilizarov fixation of refracture 248 874/7
2 left 1 2 Excision of cinereous, crepitating muscles of back group, fasciotomy, multiple longitudinal incisions, Ilizarov device with knee joint fixation Open packing/ Approximation sutures 256** From 32d day with crutches
2 15 Suturing Gradual approximation of wound edges
2 right 1 2 Excision of cinereous, crepitating muscles of back group, fasciotomy, multiple longitudinal incisions, Ilizarov fixation Open packing/ Approximation sutures/ gradual approximation of wound edges 183
2 16 Suturing Gradual approximation of wound edges
3 26 Through wound edges 2 Kirshner wires conducted, suturing through the wires Gradual approximation of wound edges
3 1 3 Excised cinereous muscles, tendons, fascia, fatty tissues, skin necrosis, removing of free bone, fragments, hematomas, multiple longitudinal incisions, Ilizarov fixation**** Open packing 575*** 30 Sepsis till 7th day
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1 2 3 4 5 6 7 8
2 6 Excised muscles, tendons, fascia, fatty tissues, skin necrosis, bone ends resection by Giggle sew Open packing
3 35 Split skin grafting 500 sm2
4 91 Conducting of additional wires for fixator stabilization, tibia osteoclasia in the upper third*****
5 101 Conducting of additional wires for remounting
6 272 Conducting of additional wires for remounting Wire track infection
4 1 1 h Excised crushed muscles, tendons, fascia, fatty tissues, skin necrosis cutting off the detached skin and perforated split skin grafting (by the graft taking from this futile flap), Ilizarov fixation****** Open packing 125 21 Lysis of 40% transplant, wire track infection
2 68 Split skin grafting 350 sm2
3 138 Ilizarov fixation 210 Eczema
4 163 Wires conducted through foot bones for equinus correction 84
5 1166 Applying of fixator for equinus correction 84
*- frame from foot was removed in 67 days
** - circular ring from femus was removed in 56 days
*** - frame from foot was removed in 98 days after Ilizarov device appliance
**** - bone defect 10 sm.
***** - for bifocal osteosynthesis; bone transport began on 12th day after osteoclasia (0.25 mm four times per day) ****** - contrical plate defect in fracture site
Table IV
Follow-up results
Case 1 2 3 4
Limb right right left right left
Duration of Follow-up 15 yrs 3,5 yrs 3,5 yrs 3 yrs 5 yrs
Bone result fair excellent excellent excellent excellent
Infection - - - - -
Union + + + + +
Deformity 10o recurv., - - - -
30o - equinus
Shortening 6 sm* 0 0 0 0
Functional result fair excellent excellent fair fair
Limb + - - + +
Rigidity ankle rigid. - - ankle rigid. ankle rigid.
Dystrophy - - - + -
Pain 2** 1 1 1 2
Activity graduated from the university, works now returned to previous job returned to previous job restored
* - is compensated by special insole 2 sm. height, walks without cane
** - 1 indicates no pain; 2 - mild pain that does not interfere with activities or sleep Рукопись поступила 28.03.97 г.
