Tip 3C tibia kırıklarında uzuv koruyucu yaklaşım ve ampütasyon

Öz

Amaç: Bu çalışmanın amacı Tip 3C tibia kırığı sonrası uzuv koruyucu yaklaşım ve primer ampütasyon uygulanan hastaların sonuçlarının değerlendirilmesi ve toplum standartlarıyla karşılaştırılması idi. Çalışma planı: 1993-2009 yılları arasında Tip 3C tibia kırığı tanısıyla uzuv koruyucu yaklaşım uygulanan 20 hasta ile primer ampütasyon uygulanan 14 hasta, ortalama 5.3 yıl takip süresi sonunda değerlendirildi. Grupların tedavi süreleri, komplikasyonlar, ameliyat sayıları ve işe dönüş durumları karşılaştırıldı. Yaşam kalitesi değerlendirilmesinde Kısa Form-36 (KF-36) kullanıldı; etki alanları hasta grupları arasında ve toplum standart değerleriyle karşılaştırıldı. Bulgular: Uzuv koruyucu yaklaşım uygulanan hastaların primer ampütasyon grubuna göre daha uzun tedavi sürelerinin sonunda daha fazla ameliyat geçirdikleri ve komplikasyon yaşadıkları görüldü. Uzuv koruyucu yaklaşım grubunda işe dönüş yüzdesi %59, ampütasyon grubunda %71 olarak bulundu. KF-36 etki alanlarının tümünde uzuv koruyucu yaklaşım ve primer ampütasyon uygulanan hastalar arasında istatistiksel fark saptanmadı. Hastaların fiziksel fonksiyonları, sosyal fonksiyonları, emosyonel durumları ve ağrıları toplum değerlerinden istatistiksel olarak düşük bulundu. Çıkarımlar: Tip 3C tibia kırıkları her iki tedavi yönteminde de hastaların yaşam kalitesi üzerinde olumsuz etkilere neden olmaktadır. Hastalar, tedavi sonunda topluma oranla daha kısıtlı bir fonksiyonel kapasite, ağrı komplikasyonları ve işe dönüş sorunları konusunda bilgilendirilmelidir. Ayrıca, uygun hastalar için müsait şartlar sağlandığında yüksek başarıyla uzuv koruyucu yaklaşım uygulamak mümkündür.

Anahtar Kelimeler

• Ampütasyon; komplikasyon; uzuv koruyucu yaklaşım; tibia; Tip 3C kırık; yaşam kalitesi.

Limb salvage and amputation in Type 3C tibial fractures

Öz

Objective: The aim of this study was to evaluate the results of limb salvage and primary amputation treatments in patients with Type 3C tibia fractures and compare with normative population data.
Methods: Limb salvage was performed in 20 patients and primary amputation in 14 patients with Type 3C tibia fractures between 1993 and 2009. Mean follow-up period was 5.3 years. Treatment times, complications, number of operations and return-to-work status of groups were compared. The Short Form-36 (SF-36) was used to assess quality of life and domains were compared among the patient groups and normative data.
Results: Limb salvage patients had longer treatment periods with more operations and complications than the primary amputation group. Return-to-work percentage was 59% in the limb salvage group and 71% in the amputation group. There was no statistical difference in all SF-36 domains for limb salvage and primary amputation patients. Physical functioning, social functioning, limitation due to emotional problems and pain were statistically lower in all patients than in the general population.
Conclusion: Type 3C tibia fractures treated with both limb salvage and primary amputation have negative effects on quality of life. Patients should be informed about limited functional capacity, pain complications and problems with return-to-work at the end of treatment. In addition, high rates of limb salvage can be achieved with proper conditions in suitable patients.

Anahtar Kelimeler

• Amputation
• complication
• life quality
• limb salvage
• tibia
• Type 3C fracture

Kaynakça

1. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classi- fication of type III open fractures. J Trauma 1984;24:742-6.
2. Hoogendoorn JM, van der Werken C. Grade III open tibial fractures: functional outcome and quality of life in amputees versus patients with successful reconstruction. Injury 2001; 32:329-34.
3. Giannoudis PV, Harwood PJ, Kontakis G, Allami M, Macdonald D, Kay SP, et al. Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation). Injury 2009;40:213-9.
4. Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am 1993;75:1431-41.
5. Soucacos PN, Beris AE, Xenakis TA, Malizos KN, Vekris MD. Open type IIIB and IIIC fractures treated by an ortho- pedic microsurgical team. Clin Orthop Relat Res 1995;(314): 59-66.
6. Puno RM, Grossfeld SL, Henry SL, Seligson D, Harkess J, Tsai TM. Functional outcome of patients with salvageable limbs with grades III-B and III-C open fractures of the tibia. Microsurgery 1996;17:167-73.
7. Dagum AB, Best AK, Schemitsch EH, Mahoney JL, Mahomed MN, Blight KR. Salvage after severe lower-extrem- ity trauma: are the outcomes worth the means? Plast Reconstr Surg 1999;103:1212-20.
8. MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. Characterization of patients with high-energy lower extremity trauma. J Orthop Trauma 2000;14:455-66.

9. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002;347:1924-31.
10. MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF, et al. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am 2005;87:1801-9.
11. Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg 2008;122:1796-805.
12. Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M; Evidence-Based Orthopaedic Trauma Working Group. Complex limb salvage or early amputation for severe lower- limb injury: a meta-analysis of observational studies. J Orthop Trauma 2007;21:70-6.
13. Sutherland AG, Suttie S, Alexander DA, Hutchison JD. The mind continues to matter: psychologic and physical recovery 5 years after musculoskeletal trauma. J Orthop Trauma 2011; 25:228-32.
14. Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score. Clin Orthop Relat Res 1990;(256): 80-6.
15. Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive sal- vage index. Am Surg 1987;53:205-8.
16. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568-72.
17. McNamara MG, Heckman JD, Corley FG. Severe open frac- tures of the lower extremity: a retrospective evaluation of the Mangled Extremity Severity Score (MESS). J Orthop Trauma 1994;8:81-7.
18. Russell WL, Sailors DM, Whittle TB, Fisher DF Jr, Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg 1991;213: 473-80.
19. Seekamp A, Köntopp H, Tscherne H. Hannover Fracture Scale ’98 – reevaluation and new prospects for an established score system. [Article in German] Unfallchirurg 2001;104: 601-10.
20. Ware JE Jr, Shelbourne CD. The MOS 36-item short-form health survey (SF-36). Conceptual framework and item selection. Med Care 1992;30:473-83.
21. Koçyi¤it H, Aydemir Ö, Fiflek G, Ölmez N, Memifl A. Reliability and validity of the Turkish version of the Short Form-36 (SF-36). [Article in Turkish] ‹laç ve Tedavi Dergisi 1999;12:102-6.
22. Demiral Y, Ergor G, Unal B, Semin S, Akvardar Y, Kivircik B, et al. Normative data and discriminative properties of short form 36 (SF-36) in Turkish urban population. BMC Public Health 2006;6:247.
23. Parmaksizoglu F, Koprulu AS, Unal MB, Cansu E. Early or delayed limb lengthening after acute shortening in the treat- ment of traumatic below-knee amputations and Gustilo and Anderson type IIIC open tibial fractures: The results of a case series. J Bone Joint Surg Br 2010;92:1563-7.
24. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 2001;83:3-14.
25. Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ, LEAP Study Group. Ability of lower-extremity injury severity scores to predict functional outcome after limb sal- vage. J Bone Joint Surg Am 2008;90:1738-43.
26. Bosse MJ, McCarthy ML, Jones AL, Webb LX, Sims SH, Sanders RW, et al. The insensate foot following severe lower extremity trauma: an indication for amputation? J Bone Joint Surg Am 2005;87:2601-8.
27. Glass GE, Pearse MF, Nanchahal J. Improving lower limb salvage following fractures with vascular injury: a systematic review and new management algorithm. J Plast Reconstr Aesthet Surg 2009;62:571-9.
28. Howard PW, Makin GS. Lower limb fractures with associ- ated vascular injury. J Bone Joint Surg Br 1990;72:116-20.
29. Seligson D, Ostermann PA, Henry SL, Wolley T. The man- agement of open fractures associated with arterial injury requiring vascular repair. J Trauma 1994;37:938-40.
30. O'Toole RV, Castillo RC, Pollak AN, MacKenzie EJ, Bosse MJ; LEAP Study Group. Determinants of patient satisfac- tion after severe lower-extremity injuries. J Bone Joint Surg Am 2008;90:1206-11.
31. Harris AM, Althausen PL, Kellam J, Bosse MJ, Castillo R; Lower Extremity Assessment Project (LEAP) Study Group. Complications following limb-threatening lower extremity trauma. J Orthop Trauma 2009;23:1-6.
32. Lange RH, Bach AW, Hansen ST Jr, Johansen KH. Open tibial fractures with associated vascular injuries: prognosis for limb salvage. J Trauma 1985;25:203-8.
33. Drost TF, Rosemurgy AS, Proctor D, Kearney RE. Outcome of treatment of combined orthopedic and arterial trauma to the lower extremity. J Trauma 1989;29:1331-4.