Выбор оптимальной тактики лечения пострадавших с тяжелой нестабильной травмой таза

На долю переломов таза, вызванных действием высокоэнергетических сил, приходится от 3 до 8 % всех травматических переломов костей. Эти травмы часто сопровождаются другими жизнеугрожающими повреждениями, представляя собой серьезную тактическую проблему. Имеется большое количество публикаций, посвященных преимуществам и недостаткам многоэтапной тактики оказания помощи Damage Control Orthopedics и ранней полной хирургической помощи Early Total Care. Однако наиболее трудной в отношении выбора тактики является категория пострадавших, находящихся в пограничном или гемодинамически нестабильном состоянии. Их лечение зачастую осложняется такими состояниями, как острый респираторный дистресс-синдром (ОРДС) и полиорганная недостаточность (ПОН). Критерии оценки рисков, связанных с применением одноэтапной и многоэтапной тактики лечения пострадавших с нестабильной травмой таза, не определены в достаточной мере, и хирург вынужден самостоятельно принимать решение о выборе тактики лечения, основываясь в большей степени на собственный опыт.

Цель – проанализировать результаты применения одноэтапной и многоэтапной тактик лечения пострадавших с нестабильной травмой таза, а также определить недостаточно исследованные аспекты каждой из них.

1. Кажанов И. В., Микитюк С. И., Колчанов Е. А., Петров А. В. Структура, особенности и характер сочетанных травм таза у пострадавших в травмоцентре I уровня Санкт-Петербургской агломерации // Медикобиологические и социально-психологические проблемы безопасности в чрезвычайных ситуациях. – 2019. – № 2. – С. 25–38.

2. Giannoudisand P. V., Pape H. C. Damage control orthopaedics in unstable pelvic ring injuries // Injury. – 2004. – Vol. 35, № 7. – P. 671–677.

3. Taherinia A., Saba G., Ebrahimi M. et al. Diagnostic value of intravenous oxygen saturation compared with arterial and venous base excess to predict hemorrhagic shock in multiple trauma patients // J Family Med Prim Care. – 2021. – Vol. 10, № 7. – P. 2625–2629.

4. Pohlemann T., Stengel D., Tosounidis G. et al. Survival trends and predictors of mortality in severe pelvic trauma: estimates from the German Pelvic Trauma Registry Initiative // Injury. – 2011. – Vol. 42, № 10. – P. 997–1002.

5. Coccolini F., Stahel P. F., Montori G. et al. Pelvic trauma: WSES classification and guidelines // World J Emerg Surg. – 2017. – Vol. 12. – P. 5.

6. Burgess A. R., Eastridge B. J., J. Young W. R. et al. Pelvic ring disruptions: effective classification system and treatment protocols // Journal of Trauma. – 1990. – Vol. 30, № 7. – P. 848–856.

7. ATLS Instructor Manual. Chicago, Ill: American College of Surgeons Publications, 2004.

8. Giannoudis P. V., Harwood P. J., Court-Brown C., Pape H. C. Severe and multiple trauma in older patients; incidence and mortality // Injury. – 2009. – Vol. 40, № 4. – P. 362–367.

9. Hoffmann M., Lefering R., Gruber-Rathmann M., Rueger J. M., Lehmann W. The impact of BMI on polytrauma outcome // Injury. – 2012. – Vol. 43, № 2. – P. 184–188.

10. Trentz O., Oestern H. J., Hempelmann G. Criteria for the operability of patients with multiple injuries // Unfallheilkunde. – 1978. – Vol. 81, № 6. – P. 451–458.

11. Pape H. C., Giannoudis P. V., Krettek C., Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making // Journal of Orthopaedic Trauma. – 2005. – Vol. 19, № 8. – P. 551–562.

12. O’Toole R. V., O’Brien M., Scalea T. M., Habashi N., Pollak A. N., Turen C. H. Resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries despite low use of damage control orthopedics // J Trauma. – 2009. – Vol. 67, № 5. – P. 1013–1021.

13. Shapiro M. B., Jenkins D. H., Schwab C. W., Rotondo M. F. Damage control: collective review // Journal of Trauma-Injury, Infection and Critical Care. – 2000. – Vol. 49, № 5. – P. 969–978.

14. Vallier H. A., Cureton B. A., Ekstein C., Oldenburg F. P., Wilber J. H. Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity // J Trauma. – 2010. – Vol. 69, № 3. – P. 677–684.

15. Bone L. B., Johnson K. D., Weigelt J., Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study// Journal of Bone and Joint Surgery A. – 1989. – Vol. 71, № 3. – P. 336–340.

16. Gebhard F., Huber-Lang M. Polytrauma-pathophysiology and management principles // Langenbeck’s Archives of Surgery. – 2008. – Vol. 393, № 6. – P. 825–831.

17. Walsh S. A., Hoyt B. W., Rowe C. J., Dey D., Davis T. A. Alarming Cargo: The Role of Exosomes in Trauma-Induced Inflammation // Biomolecules. – 2021. – Vol. 11, № 4. – P. 522.

18. Giannoudis P. V., Giannoudi M., Stavlas P. Damage control orthopaedics: lessons learned // Injury. – 2009. – Vol. 40 (Supple 4). – P. S47–S52.

19. Volpin G., Pfeifer R., Saveski J., Hasani I, Cohen M., Pape H. C. Damage control orthopaedics in polytraumatized patients – current concepts // J Clin Orthop Trauma. – 2021. – Vol. 12, № 1. – P. 72–82.

20. Pape H. C. Damage-control orthopedic surgery in polytrauma: influence on the clinical course and its pathogenetic background // European Instructional Lectures. – 2009. – Vol. 9. – P. 67–74.

21. Han G., Wang Z., Du Q. et al. Damage-control orthopedics versus early total care in the treatment of borderline high-energy pelvic fractures // Orthopedics. – 2014. – Vol. 37, № 12. – P. e1091–100.

22. Pape H. C., Tornetta P., 3rd, Tarkin I. et al. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery // J Am Acad Orthop Surg. – 2009. – Vol. 17, № 9. – P. 541–549.

23. Pape H. C., Giannoudis P., Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery // Am J Surg. – 2002. – Vol. 183, № 6. – P. 622–629.

24. Plaisier B. R., Meldon S. W., Super D. M., Malangoni M. A. Improved outcome after early fixation of acetabular fractures // Injury. – 2000. – Vol. 31, № 2. – P. 81–84.

25. Devaney G. L., Bulman J., King K. L., Balogh Z. J. Time to definitive fixation of pelvic and acetabular fractures // J Trauma Acute Care Surg. – 2020. – Vol. 89, № 4. – P. 730–735.

26. Vallier H. A., Moore T. A, Como J. J. et al. Compl. ications are reduced with a protocol to standardize timing of fixation based on response to resuscitation // J Orthop Surg Res. – 2015. – Vol. 10. – P. 155.

27. Costantini T. W., Coimbra R., Holcomb J. B. et al. AAST Pelvic Fracture Study Group. Current management of hemorrhage from severe pelvic fractures: results of an American Association for the Surgery of Trauma multi-institutional trial // J Trauma Acute Care Surg. 2016. – Vol. 80, № 5. – P. 717–723(discussion 723–5).

28. Schwartz D. A., Medina M., Cotton B. A. et al. Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention // J Trauma Acute Care Surg. – 2014. – Vol. 76, № 1. – P. 134–139.

29. Lin S. S., Zhou S. G., He L. S., Zhang Z. X., Zhang X. M. The effect of preperitoneal pelvic packing for hemodynamically unstable patients with pelvic fractures // Chin J Traumatol. – 2021. – Vol. 24, № 2. – P. 100–103.

30. Enninghorst N., Toth L., King K. L., McDougall D., Mackenzie S., Balogh Z. J. Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option // J Trauma Acute Care Surg. – 2010. – Vol. 68, № 4. – P. 935–941.

31. Roberts C. S., Pape H. C., Jones A. L., Malkani A. L., Rodriguez J. L., Giannoudis P. V. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma // Instructional Course Lectures. – 2005. – Vol. 54. – P. 447–462.

32. Pape H. C., Van Griensven M., Rice J. et al. Major secondary surgery in blunt trauma patients and perioperative cytokine liberation: determination of the clinical relevance of biochemical markers // Journal of Trauma-Injury, Infection and Critical Care. – 2001. – Vol. 50, № 6. – P. 989–1000.

33. Nicola R. Early total care versus damage control: current concept in the orthopedic care of polytrauma patients // ISRN Orthopedics. – 2013. – Vol. 2013. – P. 329452. 34. Jeske H. C., Larndorfer R.,

34. Jeske H. C., Larndorfer R., Krappinger D. et al. Management of hemorrhage in severe pelvic injuries // J Trauma. – 2010. – Vol. 68, № 2. – P. 415–420.

35. Halvorson J. J., Pilson H. T., Carroll E. A., Li Z. J. Orthopaedic management in the polytrauma patient // Front Med. – 2012. – Vol. 6, № 3. – P. 234–242.

36. Bradford D. S., Foster R. R., Nossel H. L. Coagulation alterations, hypoxemia, and fat embolism in fracture patients // Journal of Trauma. – 1970. – Vol. 10, № 4, P. 307–321.

37. Harwood P. J., Giannoudis P. V., Probst C., Krettek C., Pape H. C. The risk of local infective complications after damage control procedures for femoral shaft fracture // J Orthop Trauma. –2006. – Vol. 20, № 3. – P. 181–189.

38. Papakostidis C., Giannoudis P. V. Pelvic ring injuries with haemodynamic instability: efficacy of pelvic packing, a systematic review // Injury. – 2009. – Vol. 40 (Spple 4). – P. S53–S61.

39. Dutton R. P., Mackenzie C. F., Scalea T. M. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality //Journal of Trauma – Injury, Infection and Critical Care. – 2002. – Vol. 52, № 6. – P. 1141–1146.

40. Schreiber M. A., Meier E. N., Tisherman S. A. et al. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial // Journal of Trauma and Acute Care Surgery. – 2015. – Vol. 78, № 4. – P. 687–697.

41. Sems S. A., Johnson M., Cole P. A., Byrd C. T., Templeman D. C. Minnesota Orthopaedic Trauma Group. Elevated body mass index increases early complications of surgical treatment of pelvic ring injuries // J Orthop Trauma. – 2010. – Vol. 24, № 5. – P. 309–14.

42. Abdelrahman H., El-Menyar A., Keil H. et al. Patterns, management, and outcomes of traumatic pelvic fracture: insights from a multicenter study // J Orthop Surg Res. – 2020. – Vol. 15, № 1. – P. 249.

43. Küper M. A., Trulson A., Stuby F., Stöckle U. Pelvic ring fractures in the elderly // EFORT Open Reviews. – 2019. – Vol. 4, № 6. – P. 313–320. Doi: 10.1302/2058-5241.4.180062.

44. Carson J. H. Damage control orthopedics – when and why // The Journal of Lancaster General Hospital. – 2007. – Vol. 2, № 3. – P. 103–105.

45. Major Trauma: Assessment and Initial Management. National Clinical Guideline Centre. London: National Institute for Health and Care Excellence, (NICE), 2016.

46. Polytrauma Guideline Update Group. Level 3 guideline on the treatment of patients with severe/multiple injuries : AWMF Register-Nr. 012/019 // Eur J Trauma Emerg Surg. – 2018. – Vol. 44 (Supple 1). – P. 3–271.