Keywords
quality of life - Ilizarov technique - external fixators - bone lengthening - fractures, bones - pseudoarthrosis
Introduction
The use of an external fixator as a therapeutic option in the treatment of fractures or bone stretching was incorporated into the practices of orthopedics in the mid-nineteenth century.[1] In the 1950s, Gavrill Abramovich Ilizarov developed the circular external fixator that took his name, as well as the Ilizarov method, based on the concept of osteogenesis by distraction.[2]
[3] Osteogenic distraction allows the surgeon to perform limb stretching in patients with posttraumatic length discrepancy caused by bone trauma itself or secondary to osteomyelitis debridement.[4] Ilizarov employed, in his studies, the safe distraction rate to facilitate bone formation of 1 mm per day.[4]
[5] Due to this, it is important to highlight that the period of treatment with the fixator is usually long, about 15 months in cases of bone stretching,[4] resulting in alterations, even if transient, in daily life, quality of life and functionality of patients. According to Baschera et al.,[6] treatment with the circular external fixator is effective and fulfills its biological function for the proposed goal. However, it was noted that the return to previous work activities did not occur in the same time interval for all patients involved. For Elsoe et al.,[7] after treatment with the circular external fixator, moderate to severe depression rates increased. The authors associate this data with the complex degree of the fractures presented, the length of treatment, and the socioeconomic consequences and limitations that the long therapeutic follow-up imposes. According to the care required during therapy, the present study aims to evaluate, in a level 1 in trauma center, the repercussions generated by the Ilizarov method on the quality of life (functional and psychosocial) of patients undergoing treatment with the circular external fixator.
Material and Method
This study has a cross-sectional observational design and evaluates the quality of life (physical and psychosocial) of patients undergoing treatment with circular external fixator (Ilizarov method) for complications resulting from fractures and complex lesions in the lower limbs. Data were collected in two periods, in July 2018 and January 2019. The inclusion criteria used were patients who used the circular external fixator in the lower limbs during the questionnaire application and who agreed to participate in the study by signing the informed consent form. Patients submitted to external fixators with non-standard assemblies and patients with cognitive impairment or severe psychiatric disorders that compromised the application of the questionnaire were excluded. For data collection, the 36-item short form survey (SF-36) questionnaire was used, translated, adapted and validated for Portuguese.[8] This is a generic instrument for assessing the quality of life, easy to apply and understand, consisting of 36 items in 8 groups: functional capacity, physical aspects, pain, general health status, vitality, social aspects, emotional and mental health aspects.[8]
Thirty-six patients were evaluated in the present study, who answered the questionnaire at two distinct periods, maintaining a 6-month difference between the first application and the second. The period of treatment in which the questionnaire was conducted varied widely among patients, with an average of 11 months. Of the total evaluated, 75% of the patients were male and 25% were female. The age ranged from 19 to 63 years of age, with a mean of 37.9 years, and the median being 38 years. In about 80% of the patients evaluated in the study, the use of the external circular fixator was indicated for the treatment of complications of leg bone fractures, including pseudoarthrosis (PSA), osteomyelitis, bone failure and/or vicious consolidation. In the period evaluated, since the initial trauma, patients were submitted to multiple surgical procedures before the assembly of the Ilizarov system, on average each patient was submitted for 4 procedures involving surgical stabilization, soft-tissue debridement and/or bone resection, and the average permanence of the method for the end of the proposed treatment was around 15.6 months.
The statistical program R Version 3.5.1 (R Core Team) was used for data analysis. Descriptive analysis was performed by verifying the quantities and percentages for categorical variables and descriptive measures (minimum, maximum, quartiles, mean and standard deviation) for continuous variables.
Results
Among the items evaluated (functional capacity, limitation by physical aspects, pain, general health status, vitality, and social aspects) through the SF-36 questionnaire, only functional capacity and emotional aspects of the patient revealed statistically significant changes.
It was found through the application of the questionnaire and using the paired t-test, that the functional capacity of the patients increased on average 3.71 points (p < 0.05) when compared to the previous traumatic or infectious functional state, with a p < 0.001 between the parameters evaluated, ([Table 1])(initial values 30.32 ± 24.66 and final values 34.03 ± 23.47) demonstrating significant difference for this dimension and, nevertheless, improvement of the patient with treatment. In the same way, by qualitative analysis of this subitem, it is possible to affirm that patients can, even in use of the external fixator, return to perform their usual and basic activities of daily life, such as bathing without assistance, walking on the streets, using public transport, and shopping in markets.
Table 1
|
Rated items
|
Average
|
SD
|
P < 0.05
|
|
Functional capacity
|
|
|
0.001
|
|
Before
|
30.32
|
24.66
|
|
|
After
|
34.03
|
23.47
|
|
|
Difference
|
3.71
|
4.28
|
|
|
Emotional aspects
|
|
|
0.03
|
|
Before
|
25.81
|
33.01
|
|
|
After
|
34.41
|
42.59
|
|
|
Difference
|
8.6
|
21.03
|
|
The emotional aspect was another subitem of the questionnaire that presented significant alterations. At this point, it is also observed that there was an increase of 8.6 points (p < 0.05) ([Table 1]) between the first application of the questionnaire and the second, with a difference of 6 months between them and a p < 0.03 between the parameters evaluated.
In addition, 70.5% of the patients believe that, comparatively, their perception of health at the time of the questionnaire was improved in relation to that in the beginning of treatment with the method; the perception of their health improved or maintained at acceptable levels. It can be evaluated that, during the treatment and its progression, patients reported being more stimulated and, consequently, more involved with the treatment and recovery.
Discussion
In this heterogeneous group of patients submitted to the circular external fixator method for traumatic complications, such as pseudoarthrosis or bone infection, 70.5% believe that their health improved when compared to the period prior to the beginning of treatment. The improvement in functional capacity and emotional aspects demonstrated by the SF-36 questionnaire may be related to the stabilization of the initial clinical picture, the patient's understanding of the complexity of his injury, or by the use and results obtained by the Ilizarov method, as demonstrated by Wang et al.[9]
However, the improvement of the functional condition may be related to the objective of the circular external fixator, which is the treatment of pseudoarthrosis, osteomyelitis, and complex fractures; thus, the evolution of the patient's condition and the gradual return to their activities demonstrate functional improvement of the previous condition. The return to activities, and the positive evolution of the condition, with good results of the Ilizarov method, may be related to the improvement of the emotional aspect of the patient.
The satisfaction with the use of the circular external fixator obtained in our study, shown by the emotional improvement of patients, is in accordance with the literature, as shown by Baschera et al.[6] in a paper published in 2014. Through the SF-12 questionnaire, it was found that the satisfaction index of the sample studied with the treatment with circular external fixator (Ilizarov method) was 96.8%. In the same study, 91.7% of the patients said that they would undergo the same treatment again under similar circumstances if necessary.
Wang et al.,[9] in 2017, also evaluated the mental component by SF-36 in their patient series. They noticed improvement in psychological status according to the progression of treatment (the values found were 37.5 ± 4.5 and, at the end of treatment, they reached 72.5 ± 5.5, with p = 0.00). Regarding the psychological and emotional factor, it was possible to affirm with this study that patients using a circular external fixator had an improvement in signs of anxiety or depression.
In a 1997 publication, McKee et al.[10] evaluated 25 patients using the SF-36, with application of the questionnaire pre and postoperatively. In the overall score, similar to the present study, values that represent improvement of functional activity were revealed. However, as observed in this study, issues such as vitality (37 ± 4 to 46 ± 7) and physical function (38 ± 6 to 46 ± 7) did not show significant improvement, with indexes outside the reliability intervals.
As these are patients with orthopedic complications and patients resulting from fractures, the preoperative functional and emotional evaluation becomes complicated, but the literature and our work are in line regarding the good results of the Ilizarov method and the adequacy/adaptation of the patient to the method.
Conclusion
Despite the great complexity of the fractures presented, complications, treatment time and the socioeconomic consequences and limitations that therapeutic follow-up imposes, patients listed for the use of the Ilizarov circular external fixator method obtained improvement in functional and emotional aspects in relation to the beginning of treatment.
