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17Метод открывает перспективу для эндоваску-лярного лечения, введение препаратов улучшающих микроциркуляцию крови в бассейне позвоночных артерий и декомпрессии сосудов кровоснабжа-ющих спинной мозг.
Литература
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2. Tator C.H. Update on pathophysiology and pathology of acute spinal cord injury // Brain Pathol. -1995. - V.5, N4. - P. 413.
3. Salkov M, Zozylia N, Tsymbaliuk V, Dzyak L, Kozlov S, et al. (2015) New Concept of the Development of Brainstem Ischemia in the Setting of Occlusions of the Vertebral Arteries and Radicular and Medullary Arteries in the Presence of the Cervical Spinal Injury. Brain Disord Ther 4:193.doi:10.4172/2168-975X.1000193
4. Г. Лазорт Васкуляризация и гемодинамика спинного мозга / Г. Лазорт, А. Гуазе, Р. Джинджиан - М.: Медицина 1977. - 256 с.
5. Кас'янов В.О. Критерп прогнозу при травмi грудного вщщлу хребта i спинного мозку // Укран-ський медичний альманах. - 2012. - Том 15, № 4. -С. 65-68.
6. Пат. РФ № 2487660, Российская Федерация, Способ прогнозирования ушиба спинного мозга на шейном уровне /Вставская Татьяна Григорьевна (ЯЦ), Ларькин Валерий Иванович (ЯЦ), Резник Леонид Борисович (ЯЦ), Катина Мария Михайловна (ЯЦ), Приз Игорь Леонидович (ЯЦ); Патентообладатель^): Государственное бюджетное образовательное учреждение высшего профессионального образования "Омская государственная медицинская академия" Министерства здравоохранения и социального развития Российской Федерации (ГБОУ ВПО ОмГМА Минздравсоцразвития России) (ЯЦ); заявка: 2012-02-06; опубликовано: 20.07.2013.
ЛЕЧЕНИЕ БОЛЬНЫХ С ОДНОСТОРОННИМ КОСЫМ ПЕРЕЛОМОМ НИЖНЕЙ ЧЕЛЮСТИ С ПОМОЩЬЮ ОПТИМИЗИРОВАННОГО МЕТОДА ПРОВОЛОЧНОГО ШВА
Ефимов Ю.В.
д.м.н., проф. каф. хирургической стоматологии и челюстно-лицевой хирургии, ФГБОУ ВО «Волгоградский государственный медицинский университет»
Стоматов Д.В.
к.м.н., старший преподаватель кафедры челюстно-лицевой хирургии, ФГБОУ ВО «Пензенский государственный университет»
Ефимова Е.Ю. к.м.н., доцент кафедры анатомии человека, ФГБОУ ВО «Волгоградский государственный медицинский университет»
Долгова И.В.
к.м.н., ассистент кафедры стоматологии детского возраста, ФГБОУ ВО «Волгоградский государственный медицинский университет»
Стоматова И.А.
студент лечебного факультета, ФГБОУ ВО «Пензенский государственный университет»
TREATMENT OF PATIENTS WITH UNILATERAL OBLIQUE FRACTURE OF THE LOWER JAW
Efimov Y. V.
Professor of the Department of Surgical Dentistry and Maxillofacial Surgery,
Volgograd State Medical University Stomatov D. V.
Associate Professor of the Department of Maxillofacial Surgery,
Penza State University Efimova E. Y.
Associate Professor of the Department of Human Anatomy, Volgograd State Medical University Dolgova I. V.
Assistant of the Department ofpediatric dentistry, Volgograd State Medical University Stomatova I.A.
Student of medical department, Penza State University
АННОТАЦИЯ
Проведен сравнительный анализ лечения больных с односторонним косым переломом нижней челюсти. Больным группы сравнения проводили остеосинтез посредством одной минипластины по нижнему краю челюсти, больным основной группы посредством разработанного авторами костного шва. При этом использовали дополнительную иммобилизацию нижней челюсти гнутыми проволочными шинами. Сравнительный анализ результатов лечения показал высокую эффективность остеосинтеза проволочным швом по разработанной авторами методике.
ABSTRACT
A comparative analysis of the treatment of patients with unilateral oblique fracture of the mandible was carried out. Patients of the comparison group underwent osteosynthesis by means of a single mini-plate along the lower edge of the jaw, patients of the main group through the bone suture developed by the authors. In this case, additional immobilization of the mandible with curved wire bars was used. Comparative analysis of the results of treatment showed high efficiency of osteosynthesis by a wire struture according to the method developed by the authors.
Ключевые слова: перелом нижней челюсти, косой перелом, остеосинтез, проволочный шов, минеральная насыщенность.
Keywords: mandibular fracture, oblique fracture, osteosynthesis, wire suture, mineral saturation.
Treatment of affected patients with fractures of the lower jaw is one of the urgent problems of maxillofacial surgery. In the structure of injuries, this pathology occupies a special place due to both functional and cosmetic disorders. According to native and foreign clinics, fractures of the lower jaw among injuries of the bones of the face are from 70 to 85% while the incidence of oblique fractures reaches 60% [1,2,10].
Among the various methods of fixing the fragments of the lower jaw, the leading place is occupied by orthopedic methods. However, they do not always ensure accurate reposition of fragments and their stable fixation for the entire period of consolidation, especially with oblique fracture [7]. Therefore, most authors prefer surgical methods as the most effective in terms of ensuring the stability of fragments.
The most common type of osteosynthesis remains the bone suture. At the same time, the data of the scientific literature indicate an ambiguous attitude of researchers to this method. The main disadvantage of osteosynthesis with the bone strutre is the sagging of a large fragment down and the appearance of a false triangular defect in the area of the alveolar part of the lower jaw, as well as the crawling of fragments against each other when the wire is twisted, which leads to a horizontal displacement, accompanied by a shortening of the arch of the jaw, deformity of bite and the patient's face [6]
The use of osteosynthesis with titanium miniplates in this type of fracture, according to literature data and our many years of experience, can not always ensure the stability of the fragments, which is due to the varying thickness of the compact bone from the outer and inner sides of the jaw, which does not allow reliable fixing of miniscrew in it [8,9,11].
Purpose of the study. Is increasing the effectiveness of treatment of patients with unilateral oblique
fracture of the lower jaw due to optimization of osteosynthesis with a wire suture.
Objects and methods of research. In the period from 2010 - 2016. We examined and treated 69 (100%) patients with a unilateral oblique fracture of the mandible, which were divided into two groups. The comparison group was divided into 34 (49.28%) person. The main group included 35 (50.72%) of the affected patients. Criterias for inclusion of patients in the study were: the presence of unilateral oblique fracture of the mandible, informed consent of patients to participate in the study and the absence of concomitant pathology. The formation of clinical groups was carried out in accordance with the principles of simple randomization.
In patients of the comparison group, the fixation of fragments was carried out by means of osteosynthesis of the titanium miniplate along the lower edge of the jaw. The patients of the main group underwent osteosynthesis with awire suture according to the method developed by us (Patent of the Russian Federation No. 2565818 dated September 23, 2015). As an additional immobilization, bent wires with intermaxillary traction were used.
Osteosynthesis with a mini-plate was carried out according to the generally accepted procedure. Osteo-synthesis with a wire suture was performed under general anesthesia. After skeletonizing the fractured region with typical external access and eliminating the soft tissue interposition, an area of up to 0.1 cm deep was formed in the spongy layer of the medial (large) fragment along the entire fracture plane, while the untouched compact bone layer acted as an abutment (1) for the distal (small), a fragment that, after repositioning the fragments, was placed on the plate and fixed with one of the variants of the bone suture, after which the wound was layer-by-layer closed (Fig.1, a, b).
a 6
Fig. 1. Photographs of the main stages of osteosynthesis: a - skeletal fracture region with a formed ledge 1; b -
the repaired fragments fixed with a wire suture
On the day of admission to the hospital, all affected were subjected to x-ray of the lower jaw according to the standard procedure [5]. According to the radiographs, the localization of the fracture, the degree and nature of the displacement of the fragments were determined. The ratio of the tooth to the fracture plane was assessed by the presence or absence of a periodontal fissure on the side of the lesion.
The activity of reparative processes in the lesion area was assessed by X-ray patterns visually, and also by means of a computer product Adobe Photoshop 7.0. Based on the received histograms, the optical density (mineral saturation) of the fracture gap and the resorption index (Pr) were evaluated [Ippolitov Yu.A. et al., 2009].
Taking into account the fact that the bone density values in the normal are mainly dependent on the degree of its mineralization, it can be concluded that their values correspond directly. Consequently, long-term preservation of the significant difference in the density of the shadow between the fragments and the area of the intact bone will be an unfavorable prognostic sign and serve as an indication for correction of the treatment.
Statistical processing of the received data was carried out directly from the general data matrix "EXEL 10.0" with the involvement of the capabilities of the program "STATISTICA 6". The grouping of the variation series and their processing was carried out in accordance with the recommendations of VM Zaitsev &co-workers (2003).Variational statistical analysis included the determination of the following variational-statistical elements: M, m, Cv, t, p where M is the arithmetic mean, m is the arithmetic mean error, Cv is the coefficient of variation, t is the confidence coefficient, p is the coefficient of Student's reliability. Differences in mean were arithmetically considered reliable for p <0.05. Varying of the indices was considered weak if Cv did not exceed 10%, average when Cv was 11-25% and significant at Cv> 25%. At Cv> 50%, the distribution was considered asymmetric.
Results of the study and their discussion.
All the affected on the day of admission to the hospital were assessed as a satisfactory overall condition. The manifestations of the local inflammatory process were insignificant and could not have a significant effect on the course of the post-traumatic period.
When analyzing the radiographs, the fracture line passed from top to bottom and back, the displacement of the fragments was up to 1.0 cm, the width of the fracture gap was 2.22 ± 0.17 mm. There was a different in the form and extent of the area of enlightenment between the fragments, their ends are even and clear. Foci of marginal osteoporosis were not traced.
The index of mineral saturation of intacted bone was 158.32 ± 2.19 cu, the index of mineral saturation of the ends of fragments was 87.27 ± 2.17 cu. (p <0.001), while the variation of both indices was weak. The resorption index was 44.88 ± 2.21%.
On the 7th day of the postoperative period in all patients the manifestation of the local inflammatory process was insignificant. Occlusion of teeth is fixed in the usual position for them.
On the X-ray patterns of the affected comparison group, an increase in diastase between fragments to 0.4 cm and the appearance of foci of marginal osteoporosis were observed (Fig. 2, a). The stabilization of the width of the fracture was recorded in 14 patients (20.29%) in the region of the alveolar part of the lower jaw, a freely lying part of a bone 0.5 x 1.5 cm in size, the density of which corresponded to the density of the shadow of the intact bone (Fig. 2, b).
The average statistical index of mineral saturation in the comparison group patients was 77.25 ± 0.87 cu, which is much less than the baseline index and the intact bone index (p <0.001). At the same time, its variability was average (Kv = 22.42%). The resorption index, on the contrary, increased significantly (51.21 ± 0.54%) relative to the initial indicator (p <0.01).
a b
Fig. 2. Photographs of radiographs in the lateral projection ofpatients of the group comparison (a) and the
main group (b) on the 7th day after the operation.
In patients of the main group, the mineral saturation index stabilized at the preoperative level (87.48 ± 1.44 U.E., p> 0.05) with low variability (Kava = 4.99%). The resorption index (42.76 ± 1.95%) also did not have a reliable difference with respect to the initial indicator.
On the 14th day of the postoperative period in all patients, wound healing was the primary tension. However, 7 (10.14%) people in the comparison group had persistent aching pain in the lower jaw area on the side of the osteosynthesis performed. There was a slight edema of the tissues of the submaxillary region, with palpation the infiltration was not determined. No occlusion of the teeth was observed.
On radiographs in these patients there was an increase in diastase between fragments. Their ends acquired a scalloped outline, the area of the foci of marginal osteoporosis increased, and a tendency to displacement of the fragments was observed (Fig. 3a). In patients of the main group, the ends of the fragments became less distinct, the width of the fracture was stabilized at the level of the previous stage of monitoring, the foci of marginal osteoporosis were not traced. The size of the bone fragment in the area of the alveolar part of the lower jaw has significantly decreased, its edges have lost clarity. There was a marked decrease in the transparency of the fracture, in which the islets of the bone pattern were well traced (Fig. 3, b).
a b
Fig.3. Photographs of radiographs in the lateral projection of patients of the comparison group (a) and the main
group (b) on the 14th day after the operation.
The index of mineral saturation of the patients of the comparison group was (58.37 ± 1.75 cu), which is much less than the initial indicator (87.27 ± 2.17 cu), and the exponent 7 days after the operation 72.25 ± 087 USD), and the index of healthy individuals (p <0.001). The variability of the indicator was average (Kv = 22.31%). The resorption index, on the contrary, increased significantly (63.29 ± 1.55%) relative to the baseline index (44.88 ± 2.21, p <0.001) and the 7th day of observation (52.63 ± 137%, p < 0.001).
On the 21st day after the operation, 7 patients of the comparison group noted the persistence of minor aching pains in the lower jaw area on the side of the performed osteosynthesis, which were permanent.
On radiographs, an increase in diastase between fragments was recorded. The fracture gap retained an intense transparency. Foci of marginal osteoporosis have merged into one focus, forming the outline of a bone defect, along the upper edge of which formation of sequesters was noted (Fig. 4, a).
In patients of the main group, the width of the fracture slit decreased, the edges lost their clarity, a pronounced decrease in its transparency was observed, the extent of the areas of the shadow characteristic of the shadow of the intact bone increased. The size of the
bone fragment in the area of the alveolar part of the lower jaw has significantly decreased, its edges have lost clarity. The density of its shadow remained identical to that of the intact bone (Fig. 4, b).
a b
Fig. 4. Photographs of X-rays in the lateral projection ofpatients of the comparison group (a) and the main
group (b) on the 21st day after the operation.
The mineral saturation index of the comparison group patients (59.27 ± 1.69 cu) was stabilized at the level of the 14th day of observation (58.37 ± 1.75 cu, p> 0.05). The variability of the indicator was strong (Kv = 32.87%). The decrease in the resorption rate (62.56 ± 1.82%) relative to the similar index of the previous stage of observation (63.29 ± 1.55%) was unreliable (p> 0.05). The obtained data testified to the development of traumatic osteomyelitis in these patients.
In patients of the main group, the mineral saturation index was 127.41 ± 1.77 cu. and significantly exceeded the baseline (87.27 ± 2.17, p <0.001). Relative to the similar index of intact bone, the studied indicator remained significantly less (p <0.001). At the same time, its variability (Kv = 9.64%) was weak.
Thus, the results of the study showed a high stability of the osteosynthesis by the wire stature according to the method developed by us in the treatment of patients with a one-sided oblique fracture of the mandible, which allows us to consider it a method of choice and recommend for use in clinical practice.
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