Ekstremite Açık Kırıklarında Komplikasyon ve Morbidite Oranları

Amaç: Tip III A ve B açık kırıklar damar ve sinir hasarı olmamasına karşın yumuşak doku hasarı nedeniyle komplikasyonlara açık, tekrarlayan cerrahi oranları yüksek kırıklardır. Çalışmamızda ekstremite açık kırklarında tedavi tecrübemizi ve karşılaştığımız sorunları değerlendirdik. Hastalar ve Yöntem: Damar sinir lezyonu olmayan tip III açık kırıklı 14’ü erkek 1’i bayan, yaş ortalaması 28.5 olan 15 hasta çalışma grubumuzu oluşturdu. Yaralanma nedeni 6 hastada iş kazası, 6 hastada trafi k kazası 2 hastada kurşunlanma ve 1 hastada yüksekten düşme idi. Hastaların bize başvurma süresi ort 3.06 1-12 saat acile başvurduktan sonra ameliyata alınma süresi ise ort 5.2 1-36 saatti. Hastalarımızın 6’sında tip III A ve 9’unda tip III B açık kırık tespit edildi. Tscherne sınıfl amasına göre 6 hastada grade I, 6 hastada grade II, 3 hastada grade III yumuşak doku hasarı vardı. Sekiz hastaya internal osteosentez, 7 hastaya ise eksternal fi ksatör ile primer tedavi başlandı. Tüm hastalarda yara debridmanı, irrigasyon ve 3’lü antibiyotik tedavisi uygulandı. Bulgular: Hastaların takip süresi ortalama 23.2 ay bulundu. Tekrar ameliyat oranı 0.53 olarak hesaplandı. 4 hastada enfeksiyon gelişti. 1 hastada dirençli osteomiyelit nedeniyle dizaltı amputasyon uygulandı. 7 hastada kaynamama, 1 hastada kaynama gecikmesi gözlendi. Kaynama olmayan hastaların 3’ünde plak vida, 2’sinde İlizarov, 2’sinde intramedüller çivi uygulandı. Tekrar kaynamama gözlenmedi. Komplikasyon olan tüm hastalar Tscherne grade II veya III idi. Hastaların eski işlerine dönme oranı 0.8 olarak bulundu. Sonuç: Bu grup hastalar kaynama sorunları, çok sayıda tekrarlayan ameliyat ihtiyacı ve uzayan tedavilerine rağmen erken müdahale edilip, yakın takip edildiklerinde eski işlerine geri dönebilmekte ve minimum sekelle hayatlarına devam ettirebilmektedirler.

Complication and Morbidity Rates of Open Extremity Fractures

Objectives: Type III A and B open fractures are prone to complications and reoperations because of soft tissue damage. We discussed our experience and problems on open extremity fractures. Patients and methods: Fourteen male and one female patient with type III A and B open fractures formed our study group. Their average age was 28.5 years. Injury type was industrial accident in 6 patients, traffi c accident in 6 patients, gunshot injury in 2 patients and falling down in 1 patient. Patients were arrived at our hospital in average 3.06 1-12 hours and operation was started in average 5.2 1-36 hours after they have arrived. Six of patients had type III A and nine of patients had type III B open fractures. Six patients had Tscherne grade I, six patients had grade II and 3 patients have grade III soft tissue damage. Primary operation was internal osteosynthesis in 8 patients and external fi xation in 7 patients. Soft tissue debridement, irrigation and triple antibiotheraphy were performed in all patients. Results: At a mean follow-up of 23.2 months, the rate of re-operation was 0.53. Infection was observed in 4 patients. In one patient below knee amputation was performed because of resistant osteomyelitis. Non-union occurred in 7 patients and delayed union occurred in 1 patient. Non-unions were treated with plate-screw in 3 patients, with Ilizarov frame in 2 patients, with intramedullary nail in 2 patients. Non-unions were not observed after re-operations. Patients with complications were in Tscherne grade II and III group. Eighty per cent of the patients returned to their previous work. Conclusion: Despite their high rate of non-union and complication, functional results of type III A and B fractures may be acceptable with early treatment and close follow-up. Most of the patients may return their previous work.

Keywords:

fracture, osteosynthesis, non-union, complication infection,

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Haidukewvch GJ. Temporary external fi xation for the management of complex intra- and periarticular fractures of the lower extremity. J Orthop Trauma. 2002;16(9):678-85.

Rajasekaran S, Dheenadhayalan J, Babu JN, Sundararajan SR, Venkatramani H, Sabapathy SR. Immediate primary skin closure in type-III A and B open fractures: results after a minimum of fi ve years. J Bone Joint Surg Br. 2009;91(2):217-24.

Noumi T, Yokoyama K, Ohtsuka H, Nakamura K, Itoman M, Noumi T. Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis. Injury. 2005;36(9):1085-93.

Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty fi ve open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976; 58:453-458.

Tscherne H, Regel G, Pape HC, Pohlemann T, Kretteck C. nternal fi xation of multiple fractures in patients with polytrauma. Clin Orthop 1998; 347:62-78.

Helfet DL, Howery T, Sanders R, Johansen K. Limb salvage versus amputation: preliminary results of the mangled extremity severity score. Clin Orthop 1990; 256:80-86.

Sanders R, Jersinovich I, Anglen J, DiPasquale T, Herscovici D Jr. The treatment of open tibial shaft fractures using an interlocked intramedullary nail without reaming. J Orthop Trauma. 1994;8(6):504-10.

Yokoyama K, Shindo M, Itoman M, Yamamoto M, Sasamoto N. Immediate internal fi xation for open fractures of the long bones of the upper and lower extremities. J Trauma. 1994;37(2):230-6.

Öçgüder DA, Özer H, Solak S, Önem RY, Ağaoğlu S. Functional results of the Ilizarov circular external fi xator in the treatment of open tibial fractures. Acta Orthop Traumatol Turc. 2005;39(2):156-62.

İnan M, Tuncel M, Karaoğlu S, Halıcı M. Treatment of type II and III open tibial fractures with Ilizarov external fi xation. Acta Orthop Traumatol Turc. 2002;36(5):390-6

Noumi T, Yokoyama K, Ohtsuka H, Nakamura K, Itoman M. Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis. Injury. 2006;37(9):922-26

Kural C, Kaya I, Yılmaz M, Demirbaş E, Yücel B, Korkmaz M, Çetinus ME. A comparison between three irrigation methods in the debridement of contaminated bovine cancellous bone and the eff ect of duration of irrigation on the effi ciency of debridement. Acta Orthop Traumatol Turc. 2009 Aug-Oct;43(4):359-65.

Arangio GA, Lehr S, Reed JF 3rd. Reemployment of patients with surgical salvage of open, high-energy tibial fractures: an outcome study. J Trauma. 1997;42(5):942-5.