The Post Operative Management Health And Social Care Essay

Introduction

Osteogenesis imperfecta (OI) is a genetic disorder caused by defective type I collagen synthesis. Multiple fractures and deformities of long bones are frequently seen in patients with OI and can influence their ability to walk (5). Correction of bone deformity integrated with bone stabilization has been used for many years in the management of OI, especially since Sofield and Millar reported their study of multiple osteotomies and intramedullary rodding for children (1). Because of the bones are growth, fixed-length rods require frequent revision (2) and this encouraged the introduction of the telescopic intramedullary rod (TIMR), by Bailey and Dubow (3). The major problem of Bailey-Dubow expanding intramedullar rod was rod relocation frequently combined with perforation of joint, bone and soft tissue. Other complications like infections, pseudarthrosis, lack of elongation or overelongation of the rods, and loosening of the T-piece were only rarely seen (4). Unfortunately, revision rates of TIMR have been high because of weakness in material or design of the implants and continuing skeletal growth.

Ender first reported the use of multiple flexible nails for the fixation of femoral fractures (6). Ender nail used for a wide range of fractures of the femoral shaft, including simple, comminuted or segmental injuries. The use of Ender nail is comparatively easy and quick and requires little specialised instrumentation.

The purpose of this retrospective study was to evaluate the results of ender nailing of the bones of the lower extremities in children and adolescents patients with OI.

Materials and Methods

This retrospective study was carried out with the approval of the Yuzuncu Yil University School of Medicine Ethics Committee. Patients who were diagnosed with OI that had been treated ender nailing was included in this study between January 2010 and January 2013. We have been using Ender nail in the treatment of OI with long bone fractures in our hospital since 2009. We treated 11 femoral fracture cases with the Ender nail.

A total of 33 lower limb segments were treated, using 14 telescoping Sheffield rods (9 femoral and 5 tibial) and 19 non-telescoping rods (11 femoral and 2 tibial) (table I).

72 primary TIMR procedures were performed in 44 femora and 28 tibiae in 25 patients.

Surgical technique

Two 3.5-mm flexible stainless steel or titanium nails were placed through medial and lateral insertion sites at the distal femoral metaphysis in a retrograde, divergent ‘‘C’’ configuration7 (Fig. 1). Nail placement was confirmed for each model using fluoroscopy.

During femoral rodding the proximal T-piece was buried under the gluteal muscle insertion just outside the greater trochanter or within 0.5 cm of the tip of the trochanter. All efforts were made to place the rod in the medullary cavity in a central position and to place the T piece into the articular half of the distal femoral and proximal tibial epiphysis (figs 1 & 2). Similarly during tibial rodding the distal T-piece was placed intra-articularly through a trans-deltoid ankle approach without the need to bury it into the distal tibial epiphysis to facilitate rod exchange (fig 3). In one patient an Ilizarov ring fixator was used as a preliminary surgical step to give some soft tissue lengthening and to decrease the amount of bone shortening (fig 4).

They performed a subperiosteal resection of the entire shaft of a long bone, divided the bone at selected sites, threaded the pieces on to steel rods and then replaced the beaded but straightened shaft (Fig. 1).

Post-operative management

Post operative plaster immobilisation was maintained for 6 weeks in all patients except if there was a delay in union at any osteotomy site, in that case 2 to 4 weeks immobilisation was added (4 femoral and 9 tibial segments). Ambulation with the aid of wheelchair, crutches or walker was encouraged once the osteotomies had united according to each patient’s special situation. No external splintage or appliance was used once the osteotomies had completely united.

Data regarding complications and further procedures were obtained from the clinical records and radiological review. In patients who were tertiary referrals, their local orthopaedic surgeon was contacted by letter for copies of local clinical records and radiographs. The severity of osteogenesis imperfecta in each child was assessed by the methods of Sillence, Senn and Danks8 and Shapiro.9 Statistical analysis of the data was carried out using SPSS (SPSS Inc, Chertsey, UK) statistical software.

Results

There were three males and one female, ranging in age from 14 to 82 months (44.7 months mean age) at the time of surgery. Ages ranged from five to eight years (7.7 years mean age) at last follow-up. The average time from initial plat­ing to final follow-up period was four years. Thirteen bone platings were performed on eight bones. The eight bones included six femurs and two tibias. The indications for initial plat­ing of the eight bones included fracture and deformity. Of the six femurs, four were plated because of fracture, and two were plated for correction of deformity. Of the two tibias, one was plated for correction of deformity and the other because of fracture.

The complication rate in these patients was 69.2% (9 plates). The most common complication following plating was screw pull-out. Screw pull-out was seen following plating in five cases. One case involved multiple screws and required revision for stabilization. Two fractures through the plate were seen, and these underwent revision. Bending of two of the plates was observed. Of these nine complications, three instances of hardware failure led to revision: Screw pull-out required revision in one case, and two fractures went through the plate as mentioned above. Complications are listed in Table 1. There was one case of nonunion in a femur. This nonunion was noted five months after the initial plating and was revised with bone plating seven months after the initial operation.

Union was achieved in all cases within 7 weeks (range: 6–10 weeks)

The causes for revision in our series included 14 rod cortical extrusion (Fig. 3), 7 recurrences of deformity and 3 refractures [1 of them with rod bending (Fig. 4) and two with rod migration]. Infections, neurovascular complications, hyperplastic callus or nonunion did not occur in any patient.

Discussion

Because osteogenesis imperfecta (OI) is a genetic condition that is characterized by frequent bone fractures. It has no cure. For many years, surgical correction of deformities, physiotherapy, and the use of orthotic support and devices to assist mobility (eg, wheelchairs) were the primary means of treatment (10).

Bowing of long bones in patients with osteogenesis imperfecta with or without fracture is the main concern of orthopaedic surgeons as a permanent cure of the disease still remains elusive. The indications for surgery include long bone deformities prohibiting bracing and ambulation, and significant remaining linear growth.

Several studies have shown that the frequency of fractures of long bones of the lower limbs, in children with osteogenesis imperfecta, can be appreciably reduced by implanting intramedullary rods into the femur and tibia (11-16).

Intramedullary rods that have been used in osteogenesis imperfecta include telescoping rods, single non-elongating rods and dual non-elongating rods (15-16).

The goal of treatment should be directed to maximize the affected patient’s function and to prevent deformity and disability resulting from fractures. Correction of any pre-existing deformities of long bones and implantation of intramedullary rods is one option currently available for achieving this aim (7, 8).

El-Adl et al (9) reported that an unexplained increase in growth was found in three cases treated with a telescoping rod on one side and a non-telescoping rod on the other side, based on the premise that leg length was equal at the beginning of surgical treatment although the timing of surgery was different with a range from 6 weeks to 6 months.

To correct angulation and to avoid plaster immobilization in diaphyseal fractures in childhood, intramedullary nailing with Ender nails is an easy and safe method. Under radiographic control, fractures of femur, tibia, and humerus are stabilized with two crossing pins.

The current cost of a Sheffield telescoping rod at our center is the equivalent of US$1000. It is this prohibitive cost that made us look for cheaper alternative methods of fixation. Encouraged by Luhmann’s report of a few cases of dual Rush rodding of the femur [8], we adopted the technique in 1998 since two Rush rods cost us only an equivalent of US$6.

The frequency of fractures was comparable following telescoping rodding and dual Rush rodding (Table 3). This observation suggests that implanting two solid rods beside each other within the medullary cavity of the femur provides as much support to the bone against a fracture as a telescoping rod (which consists of a solid rod with a hollow sleeve) placed centrally within the medullary cavity (The choice of intramedullary devices for the femur and the tibia in osteogenesis imperfect).

Finally, the choice of the implant would depend on the efficacy of the rod in preventing fractures, the longevity of the rod before revision, the frequency of complications, the ease of surgery and cost. In our setting, we currently prefer to use a single Rush rod in the tibia and dual Rush rods in the femur on the basis of the results of this study. We believe that the additional demands on the surgeon and the increased operating time are justified in our situation, where patients cannot afford very expensive implants and where the operation theatre costs are not formidable.

Conclusion

Based on the information available in the literature and the results of this study, intramedullary rodding of long bones in osteogenesis imperfecta greatly improves the quality of life.

In our setting, we currently prefer to use a single Rush rod in the tibia and dual Rush rods in the femur on the basis of the results of this study. We believe that the additional demands on the surgeon and the increased operating time are justified in our situation, where patients cannot afford very expensive implants and where the operation theatre costs are not formidable.

Torakanterik Fize zarar verme, kemiğin osteoporotik olması nedeni ile çivileme esnasında kolay kırık oluşabilme