RU2412662C1 - Method of surgical management of patients with subtotal metatarsal bone defect and platypodia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to orthopaedics and traumatology. A cartilage is removed from a distal articular surface of a cuneiform bone. A pathological focus is resected with preserving a subchondral plate within a head of the metatarsal bone with adjacent intact bone segment and a cartilage. A graft is moved from a fibular bone into an interfragmental diastasis with a head modeled on its distal part. The graft head is covered with the preserved subchondral plate with the cartilage which is fixed to the graft with a pin inserted extraarticularly. With using crossing pins, a proximal end of the graft is moved to backside, while its distal part - in an external plantar direction. Through a proximal finger bone, a pin is inserted to be attached to a functional distraction assembly with creating distraction in a metatarsophalangeal articulation.

EFFECT: method provides restoration of anatomic position of longitudinal and transverse arches of the foot with preserving a function of the metatarsophalangeal articulation, reduced treatment length, prevented recurrent deformation.

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Description

The invention relates to medicine, in particular to orthopedics and traumatology, in particular, it is intended for the treatment of patients with subtotal defect of the metatarsal bone and flatfoot caused by it.

There is a method of treating giant cell tumors, which consists in resection of the bone within healthy tissues with the replacement of large defects with bone allo- or xenografts, but after joint resection, disability necessarily occurs. Therefore, the removal of the articular ends in osteoblastoclastoma sets the task of restoring the anatomical integrity and function, which is solved by transplanting the articular ends of the bones from corpses (p. 144) [A.S. Imamaliev. Bone xenoplasty / A.S. Imamaliev, B. Khabizhanov, I.Ya. Zhukovsky. - M.: Medicine, 1974, - 216 p.].

However, known methods for replacing large bone defects, as a rule, lead to a loss of joint function if the pathological focus is located near the articular joint. The restructuring of allosty takes a long time, often ends with a transplant fracture, especially in the absence of joint function. Joint transplantation - the operation is very rare and may not be effective in replacing small joints.

The use of endoprostheses with a subtotal defect of one of the bones that form the joint, especially on the foot, is almost impossible.

There is a method of lengthening the metatarsal bones by means of a ceramic implant made of crystalline alumina by introducing it into interfragmental diastasis from 5.2 to 9.2 mm [Yonenobu K., Takaoka K., Tsuyuquchi Y., Ono K., Tada K. Elongation of brachymetatarsy with ceramic implant: a roentgenographic evaluation of its utility. - J. Biomed. Mater. Res. - 1986. - Vol. 20. Number 8. - P.1249-1256].

However, the known method allows to extend the metatarsal bone by a small amount and is not applicable for subtotal defects, since even years to cover a newly transplanted bone with a small transplant are required.

In addition, this method cannot provide the engraftment of the preserved articular surface in the region of the head of the metatarsal bone after subtotal resection of the tumor of the latter.

The present invention is to develop a method for restoring the integrity of the metatarsal bone, maintaining the function of the metatarsophalangeal joint, as well as modeling the longitudinal and transverse arches of the foot.

The problem is solved in that in the method of surgical treatment of patients with a subtotal defect of the metatarsal bone and the flatfoot caused by it, cartilage is removed from the distal articular surface of the sphenoid bone, the pathological focus is resected, keeping the subchondral plate in the region of the metatarsal head with the adjacent unaffected bone and cartilage , then model the head on the distal part of the graft, covering it with a preserved subchondral plate with cartilage, which is fixed to the graft with a spoke, carried out extrajudicially, by means of crossed knitting needles, the proximal end of the graft is moved to the back side, and the distal part of it in the outer-plantar direction, to create distraction in the metatarsophalangeal joint, a spoke is inserted through the main phalanx of the finger, which is fixed to the distraction functional unit.

The present invention is illustrated by a detailed description and copies of x-rays, in which:

Figure 1 - diagram of the operation and transosseous osteosynthesis of the foot;

Figure 2 - copy of the x-ray of the left foot with subtotal lesion of the I metatarsal bone osteoblastoclastoma (before surgery);

Figure 3 is a copy of x-ray of the left foot after tumor resection and osteosynthesis of the forefoot using the Ilizarov apparatus;

4 is a copy of x-rays of the left foot after removal of the Ilizarov apparatus.

The method is as follows.

In the operating room under epidural anesthesia, after treating the surgical field with an antiseptic, a linear incision of the soft tissues is performed in the projection of the metatarsal bone, taking into account the location of the neurovascular formations.

Then, the pathological lesion is excised, preserving the subchondral plate with the adjacent unaffected bone and cartilage, and they also form a graft bed and remove the cartilage from the distal articular surface of the sphenoid bone.

Through a linear incision in the middle third of the leg, a fragment of the fibula is resected in longitudinal dimensions, corresponding to the size of the defect of the metatarsal bone. Then the graft is placed in the formed bed, modeling the head on the distal part of the graft, covering it with a subchondral plate with cartilage stored in the region of the head of the metatarsal bone.

A subchondral plate with an adjacent bone and cartilage is fixed to the graft with an extra-articular needle. By means of crossed knitting needles, the proximal end of the graft is moved to the back side, and the distal part of it in the outer-plantar direction, to create distraction in the metatarsophalangeal joint.

To unload the metatarsophalangeal joint and perform movements in it through the main phalanx of the finger, a spoke is held, which is fixed to the distraction functional unit. The wound is sutured in layers.

Spokes, including through the bones of the tarsus, are fixed to the external support of the Ilizarov apparatus (Figure 1).

Clinical observation.

Patient Z., 66, a resident of the city of Tyumen, was admitted to the Tyumen Design Bureau No. 2 with complaints of deformation of the forefoot of the left foot and pain during exercise due to the volumetric process in the I metatarsal bone, and as a result of flattening of the longitudinal and transverse arches of the left foot ( Figure 2).

We performed an operation under epidural anesthesia. A linear section of soft tissues was made along the medial side in the projection of the first metatarsal bone of the left foot, 8 cm long. Then, osteoblastoclastoma I of the metatarsal bone was resected, while maintaining the subchondral plate in the region of the head of the latter with the adjacent unaffected bone and cartilage. Cartilage from the distal articular surface of the medial sphenoid bone is removed.

Through a linear incision at the border of the middle and lower third of the lower leg, an autograft from the fibula, proportional to the defect of the metatarsal bone I, was excised (Figure 3).

After modeling the head on the distal part of the graft and covering it with a preserved subchondral plate with cartilage, the graft was placed in the formed bed. The wounds were stitched in layers.

A subchondral plate with an adjacent bone and cartilage is fixed to the graft with an extra-articular needle. By means of crossed knitting needles, the proximal end of the graft is moved to the back side, and the distal part of it in the outer-plantar direction is extra-articular to ensure movements in the metatarsophalangeal joint.

To unload the metatarsophalangeal joint and perform movements in it through the main phalanx of the finger, a spoke was held, which was fixed to the distraction functional unit.

Spokes, including through the tarsal bones, were fixed in the external support of the Ilizarov apparatus (Figure 3).

Fixation by the Ilizarov apparatus lasted 65 days. Additional immobilization, after removal of the Ilizarov apparatus, was not carried out (Figure 4).

1.5 months after removal of the Ilizarov apparatus, the patient switched to a full load on the operated limb, using ordinary shoes. Long-term result after 3 years. The patient walks in ordinary shoes, without additional means of support, there is no pain, the functional load is unlimited, she continues to work as a journalist, and she has a full function in the I metatarsophalangeal joint. There is no recurrence of osteoblastoclastoma.

The proposed method allows to obtain the following positive effects.

Firstly, it provides complete anatomical restoration of the metatarsal bone, while reducing treatment time, since the bone defect is simultaneously replaced throughout. In addition, the preservation of the function of the metatarsophalangeal joint allows you to restore the roll of the foot at this level, and therefore the functioning of the remaining metatarsophalangeal joints, therefore, the elasticity of the gait.

Secondly, this method allows to prevent recurrence of deformation, since the consolidation of the moved bone graft is achieved both with the sphenoid bone and the distal metathesis of the metatarsal bone. Unlike distraction regenerate, it will not change its shape under load.

Thirdly, the proposed method allows to restore the longitudinal and transverse arches of the foot.

Fourth, this method, by maintaining the function of the metatarsophalangeal joint, eliminates the excessive load on the graft, and therefore the cause of pathological fractures of the graft.

In addition, the proposed method is used in the Tyumen regional trauma and orthopedic center.

Claims (1)

A method for replacing a subtotal defect of the metatarsal bone by moving to the interfragment diastasis of the graft, characterized in that, in order to restore bone integrity, maintain the function of the metatarsophalangeal joint, as well as to simulate the longitudinal and transverse arches of the foot, cartilage is removed from the distal articular surface of the sphenoid bone, and a pathological focus is resected. keeping the subchondral plate in the region of the head of the metatarsal bone with the adjacent unaffected bone and cartilage, then the heads are modeled on the distal part of the graft bone graft, covering it with a preserved subchondral plate with cartilage, which is fixed extra-articularly with a knitting needle, by means of crossed needles, the proximal end of the graft is moved to the back side, and its distal part in the outward-plantar direction, and to create distractions in the metatarsophalangeal joint through the main phalanx of the finger carry a spoke, which is fixed to a functional distraction unit.

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