Results of treatment of massive dhaphysal defects of the femor after gunshot wounds using additive technologies

   Introduction. The problem of replacing femoral defects after gunshot fractures is one of the most difficult in traumatology and orthopedics.

   The purpose of the study was to compare the results of surgical treatment of patients with gunshot defects of the femoral diaphysis using additive technologies and the method of compression-distraction osteosynthesis according to Ilizarov.

   Material and methods. During the period from 2019 to 2023, a prospective single-center sequential controlled study was conducted, which included twenty wounded patients with gunshot circular defects of the middle third of the femoral diaphysis (more than 7 cm). The main group (I - 8 wounded) had femoral defects replaced using additive technology - an individually manufactured implant filled with auto- and allografts and fixed with a locking intramedullary pin; the control group (II - 12 wounded) had femoral defects replaced using the compression-distraction method osteosynthesis according to Ilizarov. The age of the patients was 29.3 ± 3.3 years, the size of the bone defect was 9.8 ± 2.4 cm. The severity of the condition on the VHS-SP scale was estimated at an average of 12.2 ± 1.5 points.

   Results. The duration of inpatient treatment for patients in group I was significantly shorter compared to group II: 62.1 ± 12.7 and 112.0 ± 37.0 days, respectively. The average time for anatomical restoration or integration of a 3-D implant for 7 patients in group I who completed treatment with a positive result was 170.9 ± 19.7 days. While in group II, replacement of the defect with bone transport and fusion of fragments was achieved after 275.7 ± 76.7 days. The return of the wounded to the previous level of physical activity and to military service without changing the fitness category was achieved in 5 (62.5 %) people out of 8 in group I and in 7 (58.3 %) out of 12 in group II - the differences are not statistically significant. According to the LEFS scale, a more rapid and complete recovery was observed in group I compared to group II: after 12 months, these indicators increased to 70.9±6.1 and 61.43±6.9 points, respectively.

   Conclusion. The use of additive technologies in the treatment of gunshot defects of the femur makes it possible to quickly reconstruct the bone and obtain a weight-bearing limb, reduce the time of hospital treatment and return the wounded to duty, but the long-term consequences of this treatment require further study.

1. Metodicheskie rekomendatsii po lecheniyu boevoi khirurgicheskoi travmy / D. V. Trishkin, E. V. Kryukov, A. P. Chuprina [i dr.]. – Sankt-Peterburg: Voenno-meditsinskaya akademiya imeni S. M. Kirova, 2022. – 373 p.

2. Kerimov A. A., Nelin N. I., Perekhodov S.N., Fominykh E. M., Ivashkin A. N. Aktual’nye podkhody k khirurgicheskoi obrabotke ognestrel’nykh travm konechnostei // Meditsinskii vestnik MVD / 2023;3(124):2-6.

3. Ilizarov G. A. The principles of the Ilizarov method. Bull Hosp Jt Dis Orthop Inst. 1988; 48:1–11.

4. Sen C, Kocaoglu M, Eralp L, et al. Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases. J Orthop Trauma. 2004; 18:150–157. doi: 10.1097/00005131-200403000-00005.

5. Chaddha M, Gulati D, Singh AP, et al. Management of massive post-traumatic bone defects in the lower limb with the Ilizarov technique. Acta Orthop Belg. 2010; 76:811–820.

6. Papakostidis C, Bhandari M, Giannoudis PV. Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications, and clinical results; a systematic review and meta-analysis. Bone Joint J. 2013;95-B:1673–1680. doi: 10.1302/0301-620X.95B12.32385.

7. Toros T, Ozaksar K. Reconstruction of traumatic tubular bone defects using vascularized fibular graft. Injury. 2021 Oct;52(10):2926-2934. doi: 10.1016/j.injury.2019.08.013

8. Petrella G, Tosi D, Pantaleoni F, Adani R. Vascularized bone grafts for post-traumatic defects in the upper extremity. Arch Plast Surg. 2021 Jan;48(1):84-90. doi: 10.5999/aps.2020.00969

9. Tong K, Zhong Z, Peng Y, Lin C, Cao S, Yang Y, Wang G. Masquelet technique versus Ilizarov bone transport for reconstruction of lower extremity bone defects following posttraumatic osteomyelitis. Injury. 2017 Jul;48(7):1616-1622. doi: 10.1016/j.injury.2017.03.042.

10. Masquelet A, Kanakaris NK, Obert L, et al. Bone repair using the Masquelet technique. J Bone Joint Surg Am. 2019;101:1024–1036. doi: 10.2106/JBJS.18.00842.

11. Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. OrthopClinNorthAm. 2010;41:27–37. doi: 10.1016/j.ocl.2009.07.011.

12. Khominets V.V., Shchukin A. V., Mikhailov S. V., Foos I.V. Osobennosti lecheniya ranenykh s ognestrel’nymi perelomami dlinnykh kostei konechnostei metodom posledovatel’nogo vnutrennego osteosinteza / Politravma. 2017;(3):12-22. ISSN 2541-867X

13. Davydov D.V., Brizhan’ L.K., Nelin N.I., Grechukhin D.A. Vozmozhnosti i perspektivy primeneniya AVF pri okazanii pervichnoi spetsializirovannoi travmatologicheskoi pomoshchi v lokal’nykh voennykh konfliktakh i chrezvychainykh situatsiyakh V sbornike: VI Pirogovskii forum travmatologov-ortopedov, posvyashchennyi 50-letiyu kafedry travmatologii, ortopedii i meditsiny katastrof MGMSU im. A.I. Evdokimova. Sbornik materialov foruma. Moskva, 2021:63-64.

14. Artem’ev A. A., Ivashkin A.N., Solov’ev Yu.S., Sysoev I.A. Ukorachivayushchaya rezektsiya kak naibolee ratsional’nyi variant lecheniya infitsirovannykh lozhnykh sustavov i defektov dlinnykh kostei V knige: Travma 2018: mul’tidistsiplinarnyi podkhod. Sbornik tezisov Mezhdunarodnoi konferentsii. Rossiiskii natsional’nyi issledovatel’skii universitet im. N. I. Pirogova. 2018:27-28.

15. Lerner, A., Reis, N.D., Soudry, M.: Primary limb shortening, angulation, and rotation to facilitate the closure of massive limb wounds without complex grafting procedures, combined with secondary corticotomy for limb reconstruction. Curr. Opin. Orthop. 2009;(20):191–194 DOI: 10.1097/BCO.0b013e318193bfaa

16. Barabash A. P., Kesov L. A., Barabash Yu. A., Shpinyak S.P. Zameshchenie obshirnykh diafizarnykh defektov dlinnykh kostei konechnostei // Travmatologiya i ortopediya Rossii. 2014; (20)2:93-99.

17. Adamczyk A, Meulenkamp B, Wilken G, Papp S. Managing bone loss in open fractures. OTA Int. 2020 Mar 23;3(1): e059. doi: 10.1097/OI9.0000000000000059

18. Fillat-Gomà F, Marcano-Fernández FA, Coderch-Navarro S, Martínez-Carreres L, Berenguer A. 3D printing innovation: New insights into upper extremity surgery planning. Injury. 2021 Jul;(52)4:117-124. doi: 10.1016/j.injury.2021.01.048

19. Bizzotto N, Tami I, Santucci A, Adani R, Poggi P, Romani D, Carpeggiani G, Ferraro F, Festa S, Magnan B. 3D Printed replica of articular fractures for surgical planning and patient consent: a two years multi-centric experience. 3D Print Med. 2015;2(1):2. doi: 10.1186/s41205-016-0006-8

20. Yarikov A.V., Gorbatov R. O., Denisov A. A., Smirnov I. I., Fraerman A.P., Sosnin A. G., Perl’mutter O.A., Kalinkin A. A. Primenenie additivnykh tekhnologii 3D-pechati v neirokhirurgii, vertebrologii, travmatologii i ortopedii. Klinicheskaya praktika. 2021;12(1):90–104.

21. Calvo-Haro, J.A., Pascau, J., Mediavilla-Santos, L. et al. Conceptual evolution of 3D printing in orthopedic surgery and traumatology: from “do it yourself” to “point of care manufacturing”. BMC Musculoskelet Disord 22, 360 (2021). doi: 10.1186/s12891-021-04224-6.

22. Zhang J, Wehrle E, Rubert M, Müller R. 3D Bioprinting of Human Tissues: Biofabrication, Bioinks, and Bioreactors. Int J Mol Sci. 2021 Apr 12;22(8):3971. doi: 10.3390/ijms22083971.

23. Zhu J, Wang Y, Zhong L, Pan F, Wang J. Advances in tissue engineering of vasculature through three-dimensional bioprinting. Dev Dyn. 2021 Dec;250(12):1717-1738. doi: 10.1002/dvdy.385

24. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther. 1999 Apr; 79(4):371-83.

25. Long WT, Brien EW, Boucree JB Jr, Filler B, Stark HH, Dorr LD. Management of civilian gunshot injuries to the hip. Orthop Clin North Am. 1995 Jan;26(1):123-31.

26. Baum GR, Baum JT, Hayward D, MacKay BJ. Gunshot Wounds: Ballistics, Pathology, and Treatment Recommendations, with a Focus on Retained Bullets. Orthop Res Rev. 2022;(14):293-317. doi: 10.2147/ORR.S378278.