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Fractures in patients with Poliomyelitis: Past or current Challenge?
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Fractures in patients with Poliomyelitis: Past or current Challenge?R P. Checa Betegón∗, J. Valle Cruz, J. García Coiradas, A. Rodríguez González, A. González Pérez, E. Torrecilla Cifuentes, F. Marco Department of Traumatology and Orthopaedic Surgery, Hospital Clínico Universitario San Carlos, Madrid, Spain
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Article history: Accepted 8 February 2020 Available online xxx Keyword: Polio Lower limb fractures Dysplasic limbs Neurologic conditions Polio fractures Surgery in dysplasic limbs Poliomyelitis
a b s t r a c t Fractures in poliomyelitic limbs are a challenge to surgeons, due to polio’s sequelae and morphological disorders, which make conventional osteosynthesis difficult. We present a retrospective study of 62 patients and 73 non-simultaneous fractures in their lower limbs. Average age was 61,7 years and 53,2% were females. We analyzed the preinjury functional level, etiology of the fracture, fracture pattern, treatment used (be conservative or surgical), and implant used in surgical cases. We treated 85,1% of them surgically and 37,9% of them maintained the same functional situation as before the fracture. 55,4% of them experienced the need to add some mechanical aids after the lesion and 6,8% lost the ability to walk. Most of the surgical treatments employed were similar as the ones used in non-poliomyelitic patients, although some cases required atypical implants, such as a Multiloc (® DePuy Synthes) humeral nail for a tibial shaft fracture, due to narrow bone. Mortality along the 1st year was 2.7%. We found similar functional and radiological results as those described in non-poliomyelitic limbs. © 2020 Published by Elsevier Ltd.
Introduction Poliomyelitis is a motor neuron disease of the anterior horn of the spinal cord. It leads to asymmetrical flaccid paralysis and muscle atrophy that reduces the patient’s stability and mobility and alters the gait pattern, predisposing to falls. Until the massive clinical application of vaccines, it was quite prevalent in some countries in the 50 s and, the people who suffered the epidemic during childhood is nowadays more than 65 years old, constituting a risk groups for traumatological pathology [1,13,14,16]. The post-polio syndrome consists of a variety of symptoms including pain, fatigue, weakness and muscle atrophy in previously affected areas, as well as reduced mobility. It usually occurs 30–40 years after the original infection [14]. These patients have a higher risk of falls and, subsequently, of fractures [4–6,8–10,11], which mainly affect the poliomyelitic limb [6]. Fractures in lower extremities affected by poliomyelitis pose a real challenge. The often present complex morphological patterns because of low quality bone, poorly vascularized, in limbs with altered functionality [13]. These circumstances make conventional
R This paper is part of a Supplement supported by The Orthopaedic Surgery and Traumatology Spanish Society (SECOT). ∗ Corresponding author. E-mail address: [email protected] (P. Checa Betegón).
osteosynthesis more difficult and bone healing less likely than similar fractures in healthy population [13,17]. Below we present the results obtained after surgical or conservative treatment in patients affected by poliomyelitis who suffered some type of fracture in their paretic limb. There are few articles in literature analyzing fractures in polio limbs and their treatment [13]. Objectives The purpose of this study is to analyze epidemiological parameters, fracture’s morphology and location, type of treatment (be conservative or surgical) and implant used, as well as the evolution and long-term functional outcome of patients with poliomyelitis who suffered fractures in the poliomyelitis-affected lower limb. Material and Methods We performed a retrospective descriptive study based on information obtained from our database of patients who suffered fractures in poliomyelitic lower limbs, between 1977 and 2016. We included all the patients who suffered a fracture in a lower limb previously affected by polio, and that were treated in our center from the beginning of this process during the years covered by this study
https://doi.org/10.1016/j.injury.2020.02.029 0020-1383/© 2020 Published by Elsevier Ltd.
Please cite this article as: P. Checa Betegón, J. Valle Cruz and J. García Coiradas et al., Fractures in patients with Poliomyelitis: Past or current Challenge? Injury, https://doi.org/10.1016/j.injury.2020.02.029
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In this regard, the study included 62 patients, of whom 53.2% were female and 46.8% male, and a total of 74 fractures, although none of the patients who suffered more than one fracture did so at the same time. The mean age of these patients at the time of fracture was 61.7 years (38–93), with an ASA ≥ III in 34.7% of them. The mean follow-up was 20.2 months (12–63). We didn’t include patients who suffered fractures in limbs affected by any other condition different than polio or who were not treated initially in our center, specially in surgical cases, even if the follow-up was performed in our Hospital. In this series, we analyzed fracture etiology, morphology and location, type of treatment, type of implant employed and ulterior evolution. Descriptive statistical studies were applied to obtain the mean age and time of consolidation and weight loading, percentages of type of treatments and implants based on fracture type, loss of functional status and exitus. Results Regarding the fractures observed, we found: •
• • • • • • • • •
Proximal femur, 54% (subdivided according to the region into 22.9% subcapitals, 20.3% pertrochanteric, 5.4% persubtrochanteric and 5.4% basicervical) Femoral shaft fractures (10.8%) Distal femur fractures (5.4%) Isolated fractures of the femoral condyle (1.4%). Tibial plateau fractures (4.1%) Proximal tibial metaphysis fractures (4.1%) Tibial shaft fractures (13.5%) Patellar fractures (2.7%) Ankle fractures (trimalleolar 1.4% and transyndesmal 1.4%) Tibial pilon fractures (1.4%)
In general terms, if we evaluate post-fracture and posttreatment parameters: Of all the fractures studied in our series, 85.1% were treated surgically, while 14.9% were managed non-surgically. Prior to the fracture that included them in this study, 14.5% of the patients used some type of tutor in the poliomyelitic member and 6.5% used a lift insole. 20.3% wandered without mechanical aids, 46% used a crutch, 25.7% used two crutches, 1.4% used a walker and 6.8% were unable to walk and used a wheelchair. The main cause for the fractures included in the series was the casual fall, without further specifications, representing an 86.5% approximately. Other causes were non-sports injuries (5.4%), traffic accidents (1.4%), pathological fractures (1.4%), high height falls (2.7%) or other type of trauma (2.7%) The mean loading time was approximately 3.7 weeks (2.75–11), with proximal femoral fractures being the first to initiate loading. Radiological consolidation was observed in all cases that were followed in our center, although 20.3% of them presented delayed consolidation (more than 6 months). There was no evidence of pseudoarthrosis. We registered two exitus during the first year of follow-up (2,7%), although they were unrelated to their fracture process. One patient, with a tibial diaphyseal fracture, who was initially treated conservatively. After conservative treatment failure, he was admitted in our hospital to perform endomedullary nailing. During the admission he did not present any incidence but died before the first review after a massive heart attack. The second of the deceased cases was a patient who suffered a patella fracture and who was then diagnosed of stage IV lung cancer with multiple metastases and died during admission. As for the post-treatment functional situation, 37.9% maintained the same functional situation as before the fracture; 55.4% experi-
enced deterioration and needed to introduce some mechanical aid, although they retained the ability to walk; 6.8% experienced a loss of functional status with inability to walk. Approximately 1.4% of patients are still under follow-up. This data is resumed in Table 1.
Subcapital fractures (Intracapsular) 17 cases In our center, subcapital fractures can be treated differently, depending on the age of the patient and fracture displacement: cannulated screws, total or partial arthroplasty, or conservative management. Patients in our series who suffered this kind of fracture, whose mean age was 68 years, were treated with hip arthroplasty in 52.9% of the cases; Cannulated screws in 35.3% and special arthroplasty for dysplasic limbs in approximately 5.9% (69-yearold man, who, due to the anatomical characteristics and the small diameter of his femoral canal, required a special arthroplasty for displasic limbs, so his surgery was delayed 27 days). In addition, 5.9% of the cases were managed conservatively (woman referred from GP with a consolidating subcapital fracture apparently occurring 2.5 months before). Before they suffered the episode of the fracture, 17.7% of the patients used a tutor. 47.1% maintained their previous situation and 52.9% had to increase the number of mechanical aids, but none required implementing orthesis or tutors afterwards. There were no cases of exitus nor removal of material, but 11.8% had some form of major complication (two cases of gastrointestinal infection). There were no registered cases of either prosthesis dislocation or instability. The mean consolidation time was 5 months and loading time was 1.21 weeks.
Basicervical fractures 4 cases These fractures are usually managed with endomedullary nailing in our center, although on occasion may be treated with a hip replacement. The average age was 69.3 years and no patient used a rise insole nor tutor prior to fracture. One case (25%) received conservative treatment; another patient (25%) was treated with Ender Nails (a female patient, 62 years old at the time of fracture, with a very dysplasic and atrophic limb, with a narrow medullary canal, and a good functional status). Two cases (50%) were treated with a Gamma nail. One patient (25%) maintained the same functional situation as the one he had before the fracture. The remaining three (75%) had to increase the number of mechanical aids. No case of total loss of ambulation was registered, although one case (25%) had to implement tutors. The mean consolidation time was 2.3 months, and the average loading time was 2.8 weeks.
Pertrochanteric fractures 15 cases When facing intertrochanteric fractures in non-polio patients, the usual treatment in our center is the endomedullary nailing. In the group of intertrochanteric fractures from our series, with a mean age of 64.4 years, the Gamma Nail was used in 66.7% of the cases; The DHS plate in 20%; Ender nails at 6.7% and LCP plate at 6.7%. There were no cases of conservative management. Before the fracture, 6.7% of the patients used a tutor and 6.7% used a raised insole in the polio limb. After the surgery, in 46.7% of the cases the functional situation was maintained and 53.3% had to add mechanical aids and a 13.3% required postfracture tutor. There were neither cases of loss of walking ability nor exitus, but 6.7% of the patients required removal of osteosynthesis material and 6.7% presented some type of complication (a case that presented fever of unknown origin that was resolved with empirical antibiotic coverage). Deambulation was started at 1.47 weeks on average and the mean consolidation time was 4.3 months
Please cite this article as: P. Checa Betegón, J. Valle Cruz and J. García Coiradas et al., Fractures in patients with Poliomyelitis: Past or current Challenge? Injury, https://doi.org/10.1016/j.injury.2020.02.029
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1 100,00% 3,00 7,00 72,00 0,00% 100,00% 0,00% 0,00% 1 100,00% 2,00 6,00 66,00 0,00% 0,00% 100,00% 0,00% 1 100,00% 3,50 10,00 67,00 100,00% 0,00% 0,00% 0,00%
ISOLATED FEMORAL CONDYLE TIBIAL PLAFOND TRIMALEOLLAR TRANSINDESMAL
1 100,00% 5,00 5,00 42,00 100,00% 0,00% 0,00% 0,00%
TIBIAL SHAFT
10 40,00% 5,06 6,11 59,50 20,00% 70,00% 0,00% 10,00%
PROXIMAL TIBIAL METAPHYSIS
3 33,33% 4,50 4,00 63,33 66,67% 33,33% 0,00% 0,00% 3 100,00% 5,50 7,33 71,33 0,00% 33,33% 66,67% 0,00%
TIBIAL PLATEAU
All diaphyseal femoral fractures were treated surgically. The average age was 53.5 years. The most frequent treatment in our center is the endomedullary nailing. Of the fractures in this series, 87.5% were treated with an anterograde T2 nail and 12.5% with a retrograde nail. 12.5% used a tutor prior to fracture. 87.5%, functionally, had to increase the number of mechanical aids, while 12.5% had no modifications of their baseline situation. There were neither exitus nor major complications, but 25% of patients required extraction of the osteosynthesis material (one patient required removal of the proximal locking screw by protrusion at approximately 6 months post-surgery; The second case, the same type of extraction, at 56 months postoperatively). The consolidation time was 5.44 months and the mean load was 4.81 weeks. Distal femoral fractures 4 cases
FUNCTIONALITY
FUNCTIONALITY
The surgical treatment of these fractures in non-polio patients in our center usually is based on endomedullary nailing with long Gamma nail. The mean age of this group was 68.8 years and all the cases were treated surgically. Of the total number of these fractures in our series of patients affected by polio, one case (25%) was treated with Gamma nail, another patient (25%) using Ender nails (a 67-year-old woman with a subtrochanteric fracture line and a poliomyelitic member with an endomedular canal diameter thin and curved, so that a rigid nail could not fit in, which in the immediate postoperative presented anemization, infection of surgical wound and urinary infection, processes that were all satisfactorily resolved) (SEE Fig. 1) and two (50%) with DHS plates. In this group, one of the patients (25%) required use of a tutor prior to fracture. At functional level after the fracture, one of the patients regained his previous situation; another one had to increase the number of mechanical aids and two experienced a total loss of deambulation ability. There were no cases of major complications or removal of the osteosynthesis material. The mean consolidation time was 3.4 months, and it took an average of 2.9 weeks to initiate loading Diaphyseal femoral fractures 8 cases
CASES SURGICAL TREATMENT CONSOLIDATION (MONTHS) LOADING (WEEKS) MEAN AGE RETAINED PRECISE ADDITIONAL AIDS LOSS OF AMBULATION EXITUS
2 50,00% 6,00 4,00 57,50 100,00% 0,00% 0,00% 50,00% 4 100,00% 5,50 11,00 48,50 25,00% 75,00% 0,00% 0,00% 8 100,00% 5,44 4,81 53,50 12,50% 87,50% 0,00% 0,00% 4 75,00% 2,25 2,75 69,25 25,00% 75,00% 0,00% 0,00% 17 94,12% 5,00 1,21 68,00 47,06% 52,94% 0,00% 0,00% CASES SURGICAL TREATMENT CONSOLIDATION (MONTHS) LOADING (WEEKS) MEAN AGE RETAINED PRECISE ADDITIONAL AIDS LOSS OF AMBULATION EXITUS
4 100,00% 3,38 2,88 68,75 25,00% 25,00% 50,00% 0,00%
15 100,00% 4,27 1,47 64,53 46,67% 53,33% 0,00% 0,00%
FEMORAL SHAFT BASICERVICAL SUBCAPITAL PERTROCANTHERIC PERSUBTROCANTHERIC
Table 1 Resume of the most relevant information concerning demographic data, type of treatment per fracture, mortality and functional results.
DISTAL FEMUR
PATELLA
Persubtrochanteric fractures 4 cases
In our center, we treat supraintercondilar fractures, depending on their characteristics, by either nail or plate. The mean age of the patients who suffered this type of fracture was 48.5 years, and only one of the patients (25%) used a previous tutor. All of these patients were surgically treated, and in them, osteosynthesis with plate was used in three cases (75%) and endomedullary nailing in the remaining one (25%). In this series, one of the cases (25%) retained the functional situation compared to 75%, the other three, who had to increase the number of mechanical aids. One patient required tutor postfracture. There were no cases of major complication, exitus or necessity for removal of the material. Load was initiated an average of 11 weeks after surgery, and the average consolidation time was 5.5 months. Isolated femoral condylar fractures 1 case We only had one patient with a fracture of the femoral condyle, whose age was 72 years. This case was intervened with cannulated screws. We observed functional deterioration with the necessity to increase mechanical aids. We did not find exitus, major complications nor material extractions. The weight loading started 7 weeks after surgery and required 3 months for consolidation. Patella fracture 2 cases The patellar fractures, in our institution, can be handled mainly in two ways, by tension band technique or conservatively. The
Please cite this article as: P. Checa Betegón, J. Valle Cruz and J. García Coiradas et al., Fractures in patients with Poliomyelitis: Past or current Challenge? Injury, https://doi.org/10.1016/j.injury.2020.02.029
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Fig. 1. This case represents a 67 year old woman with a subtrochanteric fracture. Her femoral canal was thin and was decided to treat with Ender endomedullary nails, instead of other thicker nails. A) Reception at emergency room B) Day after surgery C) One month after surgery.
mean age in patients with patella fracture in our study was 57.5 years. Of these two patients, one was treated surgically (50%), by resection of the inferior pole of the patella, and the other one (50%) conservatively. An exitus was recorded (one patient who has already been mentioned previously, who was diagnosed of a stage IV lung neoplasm during his admission). The loading time was 4 weeks and consolidation time 6 months, while functional status remained the same in the surviving patient.
tion, or withdrawal of material. The average load time was 4 weeks and the consolidation time was 4.5 months. Tibial diaphyseal fractures 10 cases
The treatment of patients with tibial plateau fracture can be complex and requires proper planning prior to osteosynthesis. Patients with tibial plateau fractures had a mean age of 71.3 years and one of them (33.3%) used a previous tutor. A case was treated with arthrodesis (33.3%) (a patient with a previous fracture years before, treated with primary arthrodesis, presented a delayed nonunion and a new fracture over it, and was treated with rearthrodesis), a second case was treated with a definitive external fixation (33%), and a third patient was managed by osteoshyntesis with plate (33.3%). In this group, one of the patients experienced the necessity to increase mechanical aids while the remaining two (66.7%) lost the ability to deambulate. Only one case required removal of osteosynthesis material (the patient whose fracture was treated with external fixator, which was removed after three and a half months). There were neither cases of exitus nor major complications. The average consolidation time was 5.5 months. The mean weight loading time was 7.3 weeks.
Most used treatments for tibial shaft fractures are conservative and endomedullary nailing. The patients’ mean age in our series was 59.5 years. Among these total 10 cases, six of them were treated conservatively (60%). From the remaining four, one case (10%) was treated with endomedullary nailing; another one (10%) by external fixator; one patient (10%) using Kischner wires (given the minimum degree of displacement and that the line of fracture ascended to the metaphysis, it was decided to immobilize the fracture with wires in a plaster) and another case (10%) by nailing with a Multiloc (® DePuy Synthes) nail of humerus (SEE Fig. 2). Among the 10 cases of this kind of fracture we registered, two of them (20%), recovered the functional situation while seven (70%) suffered deterioration with the need to increase mechanical aids. Before the fracture, one of them (10%) used previous tutor and 30%, three cases, rise insole. One patient died shortly after the fracture for reasons unrelated to this one (a patient with a fracture initially treated conservatively that, as a result of a new trauma suffered a re-fracture; since the displasic limb endomedular canal had a thin diameter, it was decided to nail using a humerus Multiloc (® DePuy Synthes) nail) (SEE Fig. 2). There was one case (10%) of removal of osteosynthesis material (the fracture handled with an external fixator). The average loading time was 6.1 weeks and the consolidation 5.1 months.
Proximal tibial metaphysis fracture 3 cases
Ankle fractures 2 cases
In addition to the possibility of conservative treatment, in our institution, these fractures are also treated, depending on numerous factors, with nail or plate. The mean age was 63.3 years. In this group, one case (33.3%) was treated using an endomedullary nail, while 66.7%, two cases, were treated conservatively. Of these three patients, two (66.7%) were able to return to their previous situation, whereas the remaining case (33.3%) required an increase in mechanical aids. There were no cases of exitus, major complica-
As for ankle fractures, there was one case (1.4%) of transindesmal fracture and another one (1.4%) of trimaleollar fracture, with ages of 42 and 67 years, respectively. No cases used previous tutors. They were operated with a plate osteosynthesis, which is also the usual treatment in our institution, with a complete functional recovery in both cases. No case of major complication, exitus or need for reintervention or to remove material. The loading times were 5 weeks in the transindesmal fracture and 10 weeks in the
Tibial plateau fracture 3 cases
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trimalleolar one, with consolidation times of 5 and 3.5 months, respectively. Tibial plafond fracture 1 case The management of tibial pylon fractures is complex, given the usual articular surface compromise, frequent comminution and soft tissue involvement. The most common treatment in our institution is osteosynthesis with plate and, if necessary until definitive surgery can be performed, an external fixator. Only one case (1.4%) from all the patients in this series presented a tibial pylon fracture (age of 66 years old), and was intervened with osteosynthesis with plate, which later required material extraction. The patient experienced a complete deterioration of his functional situation, with a loss of ambulation. No exitus nor major complications were recorded. Consolidation was obtained 2 months after fractures, with 6 weeks until weight loading began. Discussion
Fig. 2. This patient had a tibial shaft fracture treated conservatively initially that, as a result of a new trauma, broke again through the weak fracture’s callus. The limb was very displasic, with a narrow endomedular canal. Therefore it was decided to nail using a narrower nail, a humerus Multiloc (® DePuy Synthes) nail. A) At reception in emergency room B) 3 Months after initial fracture. Fail of consolidation with conservative treatment and broken again through the weak callus C) After endomedullary tibial nailing using a Mutiloc (® DePuy Synthes) humerus nail due to narrow displasic bone.
The polioviruses are enteroviruses transmitted orally after consumption of contaminated water or food. Despite its high infectivity, 90–95% of infections are asymptomatic, since they are limited to the digestive system [1,14] but 4–8%, of them spread through the bloodstream. Patients with paralytic polio limbs account for only 0.5% of all polio infections, when the virus infects the central nervous system and motor neurons, causing denervation of muscle fibers [1,4,14,16]. The eradication of polio has been one of the priorities in health matter since the creation of the first effective vaccine, in 1952. Initially, it was estimated that the annual incidence was 60 0,0 0 0 cases/year and since then, the rates of the disease have decreased by 99% [1,14,21]. The disappearance of new cases of this disease is one of the most important health milestones of the 20th century in our country. The highest incidence rates occurred in the 1950s. No further cases have been reported since 1988. In 2007, the WHO declared our country to be polio-free. In 2012, only 223 new cases of poliomyelitis were declared worldwide, in three countries, a significantly lower number than the 350,0 0 0 that were declared in 1988 in 125 countries. Just like it happened in our country, polio is close to eradication worldwide [1,13,14]. Although there are no new cases of poliomyelitis, this doesn’t mean that we should ignore the disease [1,10,13]. The population that suffered the epidemic during childhood is nowadays more than 65 years old, constituting a risk group for traumatological pathology [13] and, in general, of any other kind, such as respiratory or gastrointestinal [1]. Worldwide, it is estimated that there are between 12 and 20 million people living with the consequences of this disease [1,10,13], and about 70 0,0 0 0 of these people with paralysis reside in Europe [1]. Most of the current medical practitioners in developed countries have not faced polio cases or patients suffering their sequelae [1]. The rate of falls in polio survivors is four times higher [10] than in the general population [2,3,9,11,13,15], an estimated 64% risk per year [10], that increases to 79-82% risk of falling within 5 years. [4,10,11,15]. This is due to several concomitant factors, the most important of these being the quadricipital weakness [10– 12] and the collapse of the knee during the support phase of the gait, as well as the dorsiflexion deficiency of the ankle during the rolling phase [11]. It is also common to report these fractures at the end of the day and during walking, as in elderly patients, so it is possible that muscle fatigue is a contributor to these falls [11] We must add the higher incidence of osteoporosis (only 40% of polio patients have a normal bone density) [4–6,8–10,13] in this group of patients compared to the general population due to postpolio syndrome, which affects around 25–40% of polio survivors
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[1]. It is estimated that 56% of patients with polio can be diagnosed with osteoporosis and 40% with osteopenia [6], compared with 6–10% in a healthy population [6]. This, together with the increase in the number of falls, supposes a fracture risk that rises up to 38% in 5 years [4,6,8,10,11] and frequently in the affected paretic member [6] (8 out of 9 fractures of the femoral neck occur in the affected leg]. According to the facts mentioned above, it is expected that patients affected by poliomyelitis require at some point care by a trauma specialist due to a fracture in the affected limb [2,4– 6,10,13,15]. When assessing fracture risk, K.-H. Chang et al. recommended evaluating it in the shortened and affected leg, which usually presents a reduction in bone mineral density of approximately 23%, compared to 13% of the non-shortened leg [5,10]. The authors of different studies agree that patients affected by polio do not have more risk of fracture in other limbs except in the member affected by polio, despite the increase in falls. Despite the involvement of polio, these patients often perform active lives. It is estimated that approximately 19–28% need orthoses for deambulation and around 40–50% some other type of technical assistance for walking [4,5,8,11,12]. These data are similar to those we have collected in the series presented in this work. The morphological alterations resulting from the disease represent a technical challenge for the orthopedic surgeon [3,4,7,10,13]. These fractures require careful preoperative planning [2,10], careful thinking of the purpose of the treatment, considering that to maintain functionality should be a priority, instead of the anatomical restoration [12], as well as implant selection that can sometimes differ from the usual one [2,3,10,13,17]. Different methods of osteosynthesis are described in the literature: •
•
•
•
Nails of various sizes and diameters. Sometimes, however, the bone is so deformed, the fracture so comminuted, or the joint so rigid, that intramedullary fixation is not possible. [3,4,10,13,18]. It is also relevant to keep in mind that over reaming these bones with narrow endomedullary channels may provoke thermal bone necrosis [18]. In such cases, using nails originally designed for children o lower size adults may prove more appropriate [19]. Locking plates [3,10], especially useful in osteoporotic bones, since they act as an extra cortex [4]. Nevertheless, morphologic alterations in these patients make it difficult to properly couple the plate to the affected bone [3,4,10,13]. External fixator [10], for a possible difficult reduction or inability for another type of synthesis [3,4,10]. Additionaly, it may be necessary to carry out associated actions, such as pedicled bone grafts, like those described by Baksi et al. [2]. Artrhoplasties [in this series, we used only hip replacement]. However, and as previously stated, altered bones [3,4,10] as well as polio’s neuromuscular weakness may compromise the result [7,13,17,20].
It should be kept in mind that the mechanical and fixation properties of the different osteosynthesis devices may be altered in patients with polio, whose deforming forces are not often the usual ones [2,20]. To our knowledge, there are very few articles published in the literature that exhaustively analyze fractures in poliomyelitis patients and ours is one of the largest series we found [13]. The degree of bone dysplasia, atrophy and functionality of the limb undoubtedly conditions the surgeon, who can use the usual implant for that injury as well as having to carry out heterodox procedures [3–4,7,10,13]. When we analyzed the results obtained in our series, a high percentage of the fractures were treated surgically [85.1%]. This suggests that the treatment used was similar to that of the non-
poliomyelitic population, advocating for the same therapy despite the neurological condition [2–4,8,13,15,17]. Although functionally there are patients who depart from a more deteriorated baseline situation, with the need to employ tutors, orthoses and/or rise insole, the results obtained after the follow-up are satisfactory, with about 40% of patients maintaining the same functional situation that previously had and only 6.8% of patients who experienced a loss of the ability to walk. Overall, the functional results after rehabilitation show a progression comparable to that of nonpoliomyelitic patients with a similar functional level [3,8,10]. Although deambulation began latter than in non-polio patients (average 3.7 weeks overall, accounting for all fractures and approximately 1–3 weeks for hip fractures], this is perhaps due to the conditions of weakness and muscular atrophy that these patients present, which makes exhaustive physical therapy more necessary. Fractures that are usually maintained in discharge, such as supracondylar fractures of the femur, we did not observe differences compared to the same fractures in non-poliomyelitis patients. Globally, the evolution of these lesions in polio members seems comparable to analogous fractures in a population with similar characteristics, presenting rates and time of consolidation that do not differ significantly: about 12–20 weeks [3,4,8,10]. We did not find any case of pseudoarthrosis, although there was a 20% delay in consolidation. We have not recorded a high mortality, while all the cases have been unrelated to the fracture that included them in this study. Likewise, the complications recorded by fracture types respond to general complications, such as wound infections, urinary tract infections, anemia or intolerance to the osteosynthesis material, not registering any specific complication such as instability in hip arthroplasty or cut-out phenomenon in cephalomedular nails of the femur. From a quality of life perspective, it is imperative to help patients with post-polio syndrome to preserve their mobility and avoid falls and the subsequent fractures [6,11]. Conclusions The patient affected by polio and post-polio syndrome in the lower limbs will require orthopedic or surgical treatment with high probability due to their special conditions. The treatment of fractures in members affected by poliomyelitis requires a careful pre-surgical planning and individualized selection of implants offering clinical, radiological and functional results comparable to those of the general population, despite the morphological and muscular alterations, which conditions the rehabilitation process. We consider that it is imperative to help patients with this neurologic condition to preserve as much mobility as possible and avoid falls and their subsequent consequences. References [1] Groce NE, Banks LM, Stein MA. Surviving polio in a post-polio world. Soc Sci Med 2014;107:171–8. [2] Mootha AK, Sen RK, Aggarwal S, Bali K, Saini R. Management of a neglected femoral neck fracture in a limb affected by poliomyelitis - a case report. HIP Int 2011;21(2):267–9. [3] El-Sayed Khalil A. Locked plating for femoral fractures in polio patients. Arch Orthop Trauma Surg 2010;130(10):1299–304. [4] Wang W, Shi H, Chen D, Chen Y, Wang J, Wang S, Xiong J. Distal femoral fractures in post-poliomyelitis patients treated with locking compression plates. Orthop Surg 2013;5(2):118–23. [5] Chang KH, Lai CH, Chen SC, Tang IN, Hsiao WT, Liou TH, Lee CM. Femoral neck bone mineral density in ambulatory men with poliomyelitis. Osteoporos Int 2011;22(1):195–200. [6] Mohammad AF, Khan KA, Galvin L, Hardiman O, O’Connell PG. High incidence of osteoporosis and fractures in an aging post-polio population. Eur Neurol 2009;62(6):369–74.
Please cite this article as: P. Checa Betegón, J. Valle Cruz and J. García Coiradas et al., Fractures in patients with Poliomyelitis: Past or current Challenge? Injury, https://doi.org/10.1016/j.injury.2020.02.029
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[14] World Health Organization. Poliomyelitis. fact sheet. updated. March 2018. Available in: http: http://www.who.int/news-room/fact-sheets/detail/ poliomyelitis. [15] Silver JK, Aiello DD. Polio survivors: falls and subsequent injuries. Am J Phys Med Rehabil 2002 2002;81:567–70. [16] Practitioners G. The late effects of polio. Med J Aus 1991;155. [17] Hosalkar HS, Fuller DA, Rendonc N, Esquenazi A, Keenan MAE. Outcomes of total joint arthroplasties in adults with post-polio syndrome: results from a tertiary neuro-orthopaedic center. Curr Orthop Pract 2010;21(3):273–81. [18] Ochsner PE, Baumgart F, Kohler G. Heat-induced segmental necrosis after reaming of one humeral and two tibial fractures with a narrow medullary canal. Injury 1998;29(2):1–10. [19] Reynolds RAK, Legakis JE, Thomas R, Slongo TF, Hunter JB, Clavert JM. I.ntramedullary nails for pediatric diaphyseal femur fractures in older, heavier children: early results. J Children’s Ortho 2010;6(3):181–8. [20] Cameron HU. Total hip replacement in a limb severely affected by a paralitic poliomielitis. Can J. Surg 1995;38:386. [21] Rey M, Girard MP. The global eradication of poliomyelitis: progress and problems. Comp Immunol Microbiol Infect Dis. 2008;31(2–3):317–25.
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Fractures in patients with Poliomyelitis: Past or current Challenge?R P. Checa Betegón∗, J. Valle Cruz, J. García Coiradas, A. Rodríguez González, A. González Pérez, E. Torrecilla Cifuentes, F. Marco Department of Traumatology and Orthopaedic Surgery, Hospital Clínico Universitario San Carlos, Madrid, Spain
a r t i c l e
i n f o
Article history: Accepted 8 February 2020 Available online xxx Keyword: Polio Lower limb fractures Dysplasic limbs Neurologic conditions Polio fractures Surgery in dysplasic limbs Poliomyelitis
a b s t r a c t Fractures in poliomyelitic limbs are a challenge to surgeons, due to polio’s sequelae and morphological disorders, which make conventional osteosynthesis difficult. We present a retrospective study of 62 patients and 73 non-simultaneous fractures in their lower limbs. Average age was 61,7 years and 53,2% were females. We analyzed the preinjury functional level, etiology of the fracture, fracture pattern, treatment used (be conservative or surgical), and implant used in surgical cases. We treated 85,1% of them surgically and 37,9% of them maintained the same functional situation as before the fracture. 55,4% of them experienced the need to add some mechanical aids after the lesion and 6,8% lost the ability to walk. Most of the surgical treatments employed were similar as the ones used in non-poliomyelitic patients, although some cases required atypical implants, such as a Multiloc (® DePuy Synthes) humeral nail for a tibial shaft fracture, due to narrow bone. Mortality along the 1st year was 2.7%. We found similar functional and radiological results as those described in non-poliomyelitic limbs. © 2020 Published by Elsevier Ltd.
Introduction Poliomyelitis is a motor neuron disease of the anterior horn of the spinal cord. It leads to asymmetrical flaccid paralysis and muscle atrophy that reduces the patient’s stability and mobility and alters the gait pattern, predisposing to falls. Until the massive clinical application of vaccines, it was quite prevalent in some countries in the 50 s and, the people who suffered the epidemic during childhood is nowadays more than 65 years old, constituting a risk groups for traumatological pathology [1,13,14,16]. The post-polio syndrome consists of a variety of symptoms including pain, fatigue, weakness and muscle atrophy in previously affected areas, as well as reduced mobility. It usually occurs 30–40 years after the original infection [14]. These patients have a higher risk of falls and, subsequently, of fractures [4–6,8–10,11], which mainly affect the poliomyelitic limb [6]. Fractures in lower extremities affected by poliomyelitis pose a real challenge. The often present complex morphological patterns because of low quality bone, poorly vascularized, in limbs with altered functionality [13]. These circumstances make conventional
R This paper is part of a Supplement supported by The Orthopaedic Surgery and Traumatology Spanish Society (SECOT). ∗ Corresponding author. E-mail address: [email protected] (P. Checa Betegón).
osteosynthesis more difficult and bone healing less likely than similar fractures in healthy population [13,17]. Below we present the results obtained after surgical or conservative treatment in patients affected by poliomyelitis who suffered some type of fracture in their paretic limb. There are few articles in literature analyzing fractures in polio limbs and their treatment [13]. Objectives The purpose of this study is to analyze epidemiological parameters, fracture’s morphology and location, type of treatment (be conservative or surgical) and implant used, as well as the evolution and long-term functional outcome of patients with poliomyelitis who suffered fractures in the poliomyelitis-affected lower limb. Material and Methods We performed a retrospective descriptive study based on information obtained from our database of patients who suffered fractures in poliomyelitic lower limbs, between 1977 and 2016. We included all the patients who suffered a fracture in a lower limb previously affected by polio, and that were treated in our center from the beginning of this process during the years covered by this study
https://doi.org/10.1016/j.injury.2020.02.029 0020-1383/© 2020 Published by Elsevier Ltd.
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In this regard, the study included 62 patients, of whom 53.2% were female and 46.8% male, and a total of 74 fractures, although none of the patients who suffered more than one fracture did so at the same time. The mean age of these patients at the time of fracture was 61.7 years (38–93), with an ASA ≥ III in 34.7% of them. The mean follow-up was 20.2 months (12–63). We didn’t include patients who suffered fractures in limbs affected by any other condition different than polio or who were not treated initially in our center, specially in surgical cases, even if the follow-up was performed in our Hospital. In this series, we analyzed fracture etiology, morphology and location, type of treatment, type of implant employed and ulterior evolution. Descriptive statistical studies were applied to obtain the mean age and time of consolidation and weight loading, percentages of type of treatments and implants based on fracture type, loss of functional status and exitus. Results Regarding the fractures observed, we found: •
• • • • • • • • •
Proximal femur, 54% (subdivided according to the region into 22.9% subcapitals, 20.3% pertrochanteric, 5.4% persubtrochanteric and 5.4% basicervical) Femoral shaft fractures (10.8%) Distal femur fractures (5.4%) Isolated fractures of the femoral condyle (1.4%). Tibial plateau fractures (4.1%) Proximal tibial metaphysis fractures (4.1%) Tibial shaft fractures (13.5%) Patellar fractures (2.7%) Ankle fractures (trimalleolar 1.4% and transyndesmal 1.4%) Tibial pilon fractures (1.4%)
In general terms, if we evaluate post-fracture and posttreatment parameters: Of all the fractures studied in our series, 85.1% were treated surgically, while 14.9% were managed non-surgically. Prior to the fracture that included them in this study, 14.5% of the patients used some type of tutor in the poliomyelitic member and 6.5% used a lift insole. 20.3% wandered without mechanical aids, 46% used a crutch, 25.7% used two crutches, 1.4% used a walker and 6.8% were unable to walk and used a wheelchair. The main cause for the fractures included in the series was the casual fall, without further specifications, representing an 86.5% approximately. Other causes were non-sports injuries (5.4%), traffic accidents (1.4%), pathological fractures (1.4%), high height falls (2.7%) or other type of trauma (2.7%) The mean loading time was approximately 3.7 weeks (2.75–11), with proximal femoral fractures being the first to initiate loading. Radiological consolidation was observed in all cases that were followed in our center, although 20.3% of them presented delayed consolidation (more than 6 months). There was no evidence of pseudoarthrosis. We registered two exitus during the first year of follow-up (2,7%), although they were unrelated to their fracture process. One patient, with a tibial diaphyseal fracture, who was initially treated conservatively. After conservative treatment failure, he was admitted in our hospital to perform endomedullary nailing. During the admission he did not present any incidence but died before the first review after a massive heart attack. The second of the deceased cases was a patient who suffered a patella fracture and who was then diagnosed of stage IV lung cancer with multiple metastases and died during admission. As for the post-treatment functional situation, 37.9% maintained the same functional situation as before the fracture; 55.4% experi-
enced deterioration and needed to introduce some mechanical aid, although they retained the ability to walk; 6.8% experienced a loss of functional status with inability to walk. Approximately 1.4% of patients are still under follow-up. This data is resumed in Table 1.
Subcapital fractures (Intracapsular) 17 cases In our center, subcapital fractures can be treated differently, depending on the age of the patient and fracture displacement: cannulated screws, total or partial arthroplasty, or conservative management. Patients in our series who suffered this kind of fracture, whose mean age was 68 years, were treated with hip arthroplasty in 52.9% of the cases; Cannulated screws in 35.3% and special arthroplasty for dysplasic limbs in approximately 5.9% (69-yearold man, who, due to the anatomical characteristics and the small diameter of his femoral canal, required a special arthroplasty for displasic limbs, so his surgery was delayed 27 days). In addition, 5.9% of the cases were managed conservatively (woman referred from GP with a consolidating subcapital fracture apparently occurring 2.5 months before). Before they suffered the episode of the fracture, 17.7% of the patients used a tutor. 47.1% maintained their previous situation and 52.9% had to increase the number of mechanical aids, but none required implementing orthesis or tutors afterwards. There were no cases of exitus nor removal of material, but 11.8% had some form of major complication (two cases of gastrointestinal infection). There were no registered cases of either prosthesis dislocation or instability. The mean consolidation time was 5 months and loading time was 1.21 weeks.
Basicervical fractures 4 cases These fractures are usually managed with endomedullary nailing in our center, although on occasion may be treated with a hip replacement. The average age was 69.3 years and no patient used a rise insole nor tutor prior to fracture. One case (25%) received conservative treatment; another patient (25%) was treated with Ender Nails (a female patient, 62 years old at the time of fracture, with a very dysplasic and atrophic limb, with a narrow medullary canal, and a good functional status). Two cases (50%) were treated with a Gamma nail. One patient (25%) maintained the same functional situation as the one he had before the fracture. The remaining three (75%) had to increase the number of mechanical aids. No case of total loss of ambulation was registered, although one case (25%) had to implement tutors. The mean consolidation time was 2.3 months, and the average loading time was 2.8 weeks.
Pertrochanteric fractures 15 cases When facing intertrochanteric fractures in non-polio patients, the usual treatment in our center is the endomedullary nailing. In the group of intertrochanteric fractures from our series, with a mean age of 64.4 years, the Gamma Nail was used in 66.7% of the cases; The DHS plate in 20%; Ender nails at 6.7% and LCP plate at 6.7%. There were no cases of conservative management. Before the fracture, 6.7% of the patients used a tutor and 6.7% used a raised insole in the polio limb. After the surgery, in 46.7% of the cases the functional situation was maintained and 53.3% had to add mechanical aids and a 13.3% required postfracture tutor. There were neither cases of loss of walking ability nor exitus, but 6.7% of the patients required removal of osteosynthesis material and 6.7% presented some type of complication (a case that presented fever of unknown origin that was resolved with empirical antibiotic coverage). Deambulation was started at 1.47 weeks on average and the mean consolidation time was 4.3 months
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1 100,00% 3,00 7,00 72,00 0,00% 100,00% 0,00% 0,00% 1 100,00% 2,00 6,00 66,00 0,00% 0,00% 100,00% 0,00% 1 100,00% 3,50 10,00 67,00 100,00% 0,00% 0,00% 0,00%
ISOLATED FEMORAL CONDYLE TIBIAL PLAFOND TRIMALEOLLAR TRANSINDESMAL
1 100,00% 5,00 5,00 42,00 100,00% 0,00% 0,00% 0,00%
TIBIAL SHAFT
10 40,00% 5,06 6,11 59,50 20,00% 70,00% 0,00% 10,00%
PROXIMAL TIBIAL METAPHYSIS
3 33,33% 4,50 4,00 63,33 66,67% 33,33% 0,00% 0,00% 3 100,00% 5,50 7,33 71,33 0,00% 33,33% 66,67% 0,00%
TIBIAL PLATEAU
All diaphyseal femoral fractures were treated surgically. The average age was 53.5 years. The most frequent treatment in our center is the endomedullary nailing. Of the fractures in this series, 87.5% were treated with an anterograde T2 nail and 12.5% with a retrograde nail. 12.5% used a tutor prior to fracture. 87.5%, functionally, had to increase the number of mechanical aids, while 12.5% had no modifications of their baseline situation. There were neither exitus nor major complications, but 25% of patients required extraction of the osteosynthesis material (one patient required removal of the proximal locking screw by protrusion at approximately 6 months post-surgery; The second case, the same type of extraction, at 56 months postoperatively). The consolidation time was 5.44 months and the mean load was 4.81 weeks. Distal femoral fractures 4 cases
FUNCTIONALITY
FUNCTIONALITY
The surgical treatment of these fractures in non-polio patients in our center usually is based on endomedullary nailing with long Gamma nail. The mean age of this group was 68.8 years and all the cases were treated surgically. Of the total number of these fractures in our series of patients affected by polio, one case (25%) was treated with Gamma nail, another patient (25%) using Ender nails (a 67-year-old woman with a subtrochanteric fracture line and a poliomyelitic member with an endomedular canal diameter thin and curved, so that a rigid nail could not fit in, which in the immediate postoperative presented anemization, infection of surgical wound and urinary infection, processes that were all satisfactorily resolved) (SEE Fig. 1) and two (50%) with DHS plates. In this group, one of the patients (25%) required use of a tutor prior to fracture. At functional level after the fracture, one of the patients regained his previous situation; another one had to increase the number of mechanical aids and two experienced a total loss of deambulation ability. There were no cases of major complications or removal of the osteosynthesis material. The mean consolidation time was 3.4 months, and it took an average of 2.9 weeks to initiate loading Diaphyseal femoral fractures 8 cases
CASES SURGICAL TREATMENT CONSOLIDATION (MONTHS) LOADING (WEEKS) MEAN AGE RETAINED PRECISE ADDITIONAL AIDS LOSS OF AMBULATION EXITUS
2 50,00% 6,00 4,00 57,50 100,00% 0,00% 0,00% 50,00% 4 100,00% 5,50 11,00 48,50 25,00% 75,00% 0,00% 0,00% 8 100,00% 5,44 4,81 53,50 12,50% 87,50% 0,00% 0,00% 4 75,00% 2,25 2,75 69,25 25,00% 75,00% 0,00% 0,00% 17 94,12% 5,00 1,21 68,00 47,06% 52,94% 0,00% 0,00% CASES SURGICAL TREATMENT CONSOLIDATION (MONTHS) LOADING (WEEKS) MEAN AGE RETAINED PRECISE ADDITIONAL AIDS LOSS OF AMBULATION EXITUS
4 100,00% 3,38 2,88 68,75 25,00% 25,00% 50,00% 0,00%
15 100,00% 4,27 1,47 64,53 46,67% 53,33% 0,00% 0,00%
FEMORAL SHAFT BASICERVICAL SUBCAPITAL PERTROCANTHERIC PERSUBTROCANTHERIC
Table 1 Resume of the most relevant information concerning demographic data, type of treatment per fracture, mortality and functional results.
DISTAL FEMUR
PATELLA
Persubtrochanteric fractures 4 cases
In our center, we treat supraintercondilar fractures, depending on their characteristics, by either nail or plate. The mean age of the patients who suffered this type of fracture was 48.5 years, and only one of the patients (25%) used a previous tutor. All of these patients were surgically treated, and in them, osteosynthesis with plate was used in three cases (75%) and endomedullary nailing in the remaining one (25%). In this series, one of the cases (25%) retained the functional situation compared to 75%, the other three, who had to increase the number of mechanical aids. One patient required tutor postfracture. There were no cases of major complication, exitus or necessity for removal of the material. Load was initiated an average of 11 weeks after surgery, and the average consolidation time was 5.5 months. Isolated femoral condylar fractures 1 case We only had one patient with a fracture of the femoral condyle, whose age was 72 years. This case was intervened with cannulated screws. We observed functional deterioration with the necessity to increase mechanical aids. We did not find exitus, major complications nor material extractions. The weight loading started 7 weeks after surgery and required 3 months for consolidation. Patella fracture 2 cases The patellar fractures, in our institution, can be handled mainly in two ways, by tension band technique or conservatively. The
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Fig. 1. This case represents a 67 year old woman with a subtrochanteric fracture. Her femoral canal was thin and was decided to treat with Ender endomedullary nails, instead of other thicker nails. A) Reception at emergency room B) Day after surgery C) One month after surgery.
mean age in patients with patella fracture in our study was 57.5 years. Of these two patients, one was treated surgically (50%), by resection of the inferior pole of the patella, and the other one (50%) conservatively. An exitus was recorded (one patient who has already been mentioned previously, who was diagnosed of a stage IV lung neoplasm during his admission). The loading time was 4 weeks and consolidation time 6 months, while functional status remained the same in the surviving patient.
tion, or withdrawal of material. The average load time was 4 weeks and the consolidation time was 4.5 months. Tibial diaphyseal fractures 10 cases
The treatment of patients with tibial plateau fracture can be complex and requires proper planning prior to osteosynthesis. Patients with tibial plateau fractures had a mean age of 71.3 years and one of them (33.3%) used a previous tutor. A case was treated with arthrodesis (33.3%) (a patient with a previous fracture years before, treated with primary arthrodesis, presented a delayed nonunion and a new fracture over it, and was treated with rearthrodesis), a second case was treated with a definitive external fixation (33%), and a third patient was managed by osteoshyntesis with plate (33.3%). In this group, one of the patients experienced the necessity to increase mechanical aids while the remaining two (66.7%) lost the ability to deambulate. Only one case required removal of osteosynthesis material (the patient whose fracture was treated with external fixator, which was removed after three and a half months). There were neither cases of exitus nor major complications. The average consolidation time was 5.5 months. The mean weight loading time was 7.3 weeks.
Most used treatments for tibial shaft fractures are conservative and endomedullary nailing. The patients’ mean age in our series was 59.5 years. Among these total 10 cases, six of them were treated conservatively (60%). From the remaining four, one case (10%) was treated with endomedullary nailing; another one (10%) by external fixator; one patient (10%) using Kischner wires (given the minimum degree of displacement and that the line of fracture ascended to the metaphysis, it was decided to immobilize the fracture with wires in a plaster) and another case (10%) by nailing with a Multiloc (® DePuy Synthes) nail of humerus (SEE Fig. 2). Among the 10 cases of this kind of fracture we registered, two of them (20%), recovered the functional situation while seven (70%) suffered deterioration with the need to increase mechanical aids. Before the fracture, one of them (10%) used previous tutor and 30%, three cases, rise insole. One patient died shortly after the fracture for reasons unrelated to this one (a patient with a fracture initially treated conservatively that, as a result of a new trauma suffered a re-fracture; since the displasic limb endomedular canal had a thin diameter, it was decided to nail using a humerus Multiloc (® DePuy Synthes) nail) (SEE Fig. 2). There was one case (10%) of removal of osteosynthesis material (the fracture handled with an external fixator). The average loading time was 6.1 weeks and the consolidation 5.1 months.
Proximal tibial metaphysis fracture 3 cases
Ankle fractures 2 cases
In addition to the possibility of conservative treatment, in our institution, these fractures are also treated, depending on numerous factors, with nail or plate. The mean age was 63.3 years. In this group, one case (33.3%) was treated using an endomedullary nail, while 66.7%, two cases, were treated conservatively. Of these three patients, two (66.7%) were able to return to their previous situation, whereas the remaining case (33.3%) required an increase in mechanical aids. There were no cases of exitus, major complica-
As for ankle fractures, there was one case (1.4%) of transindesmal fracture and another one (1.4%) of trimaleollar fracture, with ages of 42 and 67 years, respectively. No cases used previous tutors. They were operated with a plate osteosynthesis, which is also the usual treatment in our institution, with a complete functional recovery in both cases. No case of major complication, exitus or need for reintervention or to remove material. The loading times were 5 weeks in the transindesmal fracture and 10 weeks in the
Tibial plateau fracture 3 cases
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trimalleolar one, with consolidation times of 5 and 3.5 months, respectively. Tibial plafond fracture 1 case The management of tibial pylon fractures is complex, given the usual articular surface compromise, frequent comminution and soft tissue involvement. The most common treatment in our institution is osteosynthesis with plate and, if necessary until definitive surgery can be performed, an external fixator. Only one case (1.4%) from all the patients in this series presented a tibial pylon fracture (age of 66 years old), and was intervened with osteosynthesis with plate, which later required material extraction. The patient experienced a complete deterioration of his functional situation, with a loss of ambulation. No exitus nor major complications were recorded. Consolidation was obtained 2 months after fractures, with 6 weeks until weight loading began. Discussion
Fig. 2. This patient had a tibial shaft fracture treated conservatively initially that, as a result of a new trauma, broke again through the weak fracture’s callus. The limb was very displasic, with a narrow endomedular canal. Therefore it was decided to nail using a narrower nail, a humerus Multiloc (® DePuy Synthes) nail. A) At reception in emergency room B) 3 Months after initial fracture. Fail of consolidation with conservative treatment and broken again through the weak callus C) After endomedullary tibial nailing using a Mutiloc (® DePuy Synthes) humerus nail due to narrow displasic bone.
The polioviruses are enteroviruses transmitted orally after consumption of contaminated water or food. Despite its high infectivity, 90–95% of infections are asymptomatic, since they are limited to the digestive system [1,14] but 4–8%, of them spread through the bloodstream. Patients with paralytic polio limbs account for only 0.5% of all polio infections, when the virus infects the central nervous system and motor neurons, causing denervation of muscle fibers [1,4,14,16]. The eradication of polio has been one of the priorities in health matter since the creation of the first effective vaccine, in 1952. Initially, it was estimated that the annual incidence was 60 0,0 0 0 cases/year and since then, the rates of the disease have decreased by 99% [1,14,21]. The disappearance of new cases of this disease is one of the most important health milestones of the 20th century in our country. The highest incidence rates occurred in the 1950s. No further cases have been reported since 1988. In 2007, the WHO declared our country to be polio-free. In 2012, only 223 new cases of poliomyelitis were declared worldwide, in three countries, a significantly lower number than the 350,0 0 0 that were declared in 1988 in 125 countries. Just like it happened in our country, polio is close to eradication worldwide [1,13,14]. Although there are no new cases of poliomyelitis, this doesn’t mean that we should ignore the disease [1,10,13]. The population that suffered the epidemic during childhood is nowadays more than 65 years old, constituting a risk group for traumatological pathology [13] and, in general, of any other kind, such as respiratory or gastrointestinal [1]. Worldwide, it is estimated that there are between 12 and 20 million people living with the consequences of this disease [1,10,13], and about 70 0,0 0 0 of these people with paralysis reside in Europe [1]. Most of the current medical practitioners in developed countries have not faced polio cases or patients suffering their sequelae [1]. The rate of falls in polio survivors is four times higher [10] than in the general population [2,3,9,11,13,15], an estimated 64% risk per year [10], that increases to 79-82% risk of falling within 5 years. [4,10,11,15]. This is due to several concomitant factors, the most important of these being the quadricipital weakness [10– 12] and the collapse of the knee during the support phase of the gait, as well as the dorsiflexion deficiency of the ankle during the rolling phase [11]. It is also common to report these fractures at the end of the day and during walking, as in elderly patients, so it is possible that muscle fatigue is a contributor to these falls [11] We must add the higher incidence of osteoporosis (only 40% of polio patients have a normal bone density) [4–6,8–10,13] in this group of patients compared to the general population due to postpolio syndrome, which affects around 25–40% of polio survivors
Please cite this article as: P. Checa Betegón, J. Valle Cruz and J. García Coiradas et al., Fractures in patients with Poliomyelitis: Past or current Challenge? Injury, https://doi.org/10.1016/j.injury.2020.02.029
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[1]. It is estimated that 56% of patients with polio can be diagnosed with osteoporosis and 40% with osteopenia [6], compared with 6–10% in a healthy population [6]. This, together with the increase in the number of falls, supposes a fracture risk that rises up to 38% in 5 years [4,6,8,10,11] and frequently in the affected paretic member [6] (8 out of 9 fractures of the femoral neck occur in the affected leg]. According to the facts mentioned above, it is expected that patients affected by poliomyelitis require at some point care by a trauma specialist due to a fracture in the affected limb [2,4– 6,10,13,15]. When assessing fracture risk, K.-H. Chang et al. recommended evaluating it in the shortened and affected leg, which usually presents a reduction in bone mineral density of approximately 23%, compared to 13% of the non-shortened leg [5,10]. The authors of different studies agree that patients affected by polio do not have more risk of fracture in other limbs except in the member affected by polio, despite the increase in falls. Despite the involvement of polio, these patients often perform active lives. It is estimated that approximately 19–28% need orthoses for deambulation and around 40–50% some other type of technical assistance for walking [4,5,8,11,12]. These data are similar to those we have collected in the series presented in this work. The morphological alterations resulting from the disease represent a technical challenge for the orthopedic surgeon [3,4,7,10,13]. These fractures require careful preoperative planning [2,10], careful thinking of the purpose of the treatment, considering that to maintain functionality should be a priority, instead of the anatomical restoration [12], as well as implant selection that can sometimes differ from the usual one [2,3,10,13,17]. Different methods of osteosynthesis are described in the literature: •
•
•
•
Nails of various sizes and diameters. Sometimes, however, the bone is so deformed, the fracture so comminuted, or the joint so rigid, that intramedullary fixation is not possible. [3,4,10,13,18]. It is also relevant to keep in mind that over reaming these bones with narrow endomedullary channels may provoke thermal bone necrosis [18]. In such cases, using nails originally designed for children o lower size adults may prove more appropriate [19]. Locking plates [3,10], especially useful in osteoporotic bones, since they act as an extra cortex [4]. Nevertheless, morphologic alterations in these patients make it difficult to properly couple the plate to the affected bone [3,4,10,13]. External fixator [10], for a possible difficult reduction or inability for another type of synthesis [3,4,10]. Additionaly, it may be necessary to carry out associated actions, such as pedicled bone grafts, like those described by Baksi et al. [2]. Artrhoplasties [in this series, we used only hip replacement]. However, and as previously stated, altered bones [3,4,10] as well as polio’s neuromuscular weakness may compromise the result [7,13,17,20].
It should be kept in mind that the mechanical and fixation properties of the different osteosynthesis devices may be altered in patients with polio, whose deforming forces are not often the usual ones [2,20]. To our knowledge, there are very few articles published in the literature that exhaustively analyze fractures in poliomyelitis patients and ours is one of the largest series we found [13]. The degree of bone dysplasia, atrophy and functionality of the limb undoubtedly conditions the surgeon, who can use the usual implant for that injury as well as having to carry out heterodox procedures [3–4,7,10,13]. When we analyzed the results obtained in our series, a high percentage of the fractures were treated surgically [85.1%]. This suggests that the treatment used was similar to that of the non-
poliomyelitic population, advocating for the same therapy despite the neurological condition [2–4,8,13,15,17]. Although functionally there are patients who depart from a more deteriorated baseline situation, with the need to employ tutors, orthoses and/or rise insole, the results obtained after the follow-up are satisfactory, with about 40% of patients maintaining the same functional situation that previously had and only 6.8% of patients who experienced a loss of the ability to walk. Overall, the functional results after rehabilitation show a progression comparable to that of nonpoliomyelitic patients with a similar functional level [3,8,10]. Although deambulation began latter than in non-polio patients (average 3.7 weeks overall, accounting for all fractures and approximately 1–3 weeks for hip fractures], this is perhaps due to the conditions of weakness and muscular atrophy that these patients present, which makes exhaustive physical therapy more necessary. Fractures that are usually maintained in discharge, such as supracondylar fractures of the femur, we did not observe differences compared to the same fractures in non-poliomyelitis patients. Globally, the evolution of these lesions in polio members seems comparable to analogous fractures in a population with similar characteristics, presenting rates and time of consolidation that do not differ significantly: about 12–20 weeks [3,4,8,10]. We did not find any case of pseudoarthrosis, although there was a 20% delay in consolidation. We have not recorded a high mortality, while all the cases have been unrelated to the fracture that included them in this study. Likewise, the complications recorded by fracture types respond to general complications, such as wound infections, urinary tract infections, anemia or intolerance to the osteosynthesis material, not registering any specific complication such as instability in hip arthroplasty or cut-out phenomenon in cephalomedular nails of the femur. From a quality of life perspective, it is imperative to help patients with post-polio syndrome to preserve their mobility and avoid falls and the subsequent fractures [6,11]. Conclusions The patient affected by polio and post-polio syndrome in the lower limbs will require orthopedic or surgical treatment with high probability due to their special conditions. The treatment of fractures in members affected by poliomyelitis requires a careful pre-surgical planning and individualized selection of implants offering clinical, radiological and functional results comparable to those of the general population, despite the morphological and muscular alterations, which conditions the rehabilitation process. We consider that it is imperative to help patients with this neurologic condition to preserve as much mobility as possible and avoid falls and their subsequent consequences. References [1] Groce NE, Banks LM, Stein MA. Surviving polio in a post-polio world. Soc Sci Med 2014;107:171–8. [2] Mootha AK, Sen RK, Aggarwal S, Bali K, Saini R. Management of a neglected femoral neck fracture in a limb affected by poliomyelitis - a case report. HIP Int 2011;21(2):267–9. [3] El-Sayed Khalil A. Locked plating for femoral fractures in polio patients. Arch Orthop Trauma Surg 2010;130(10):1299–304. [4] Wang W, Shi H, Chen D, Chen Y, Wang J, Wang S, Xiong J. Distal femoral fractures in post-poliomyelitis patients treated with locking compression plates. Orthop Surg 2013;5(2):118–23. [5] Chang KH, Lai CH, Chen SC, Tang IN, Hsiao WT, Liou TH, Lee CM. Femoral neck bone mineral density in ambulatory men with poliomyelitis. Osteoporos Int 2011;22(1):195–200. [6] Mohammad AF, Khan KA, Galvin L, Hardiman O, O’Connell PG. High incidence of osteoporosis and fractures in an aging post-polio population. Eur Neurol 2009;62(6):369–74.
Please cite this article as: P. Checa Betegón, J. Valle Cruz and J. García Coiradas et al., Fractures in patients with Poliomyelitis: Past or current Challenge? Injury, https://doi.org/10.1016/j.injury.2020.02.029
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Please cite this article as: P. Checa Betegón, J. Valle Cruz and J. García Coiradas et al., Fractures in patients with Poliomyelitis: Past or current Challenge? Injury, https://doi.org/10.1016/j.injury.2020.02.029