RU2535451C2 - Method for surgical management of articular compression fracture of calcaneum and bracket for implementing it - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions refers to medicine, namely to traumatology and orthopaedics for managing articular compression fractures of calcaneal bones. After the calcaneal bone is approached, fibrous canals of the fibular tendons are opened and moved upwards. Calcaneofibular and talocalcanean ligaments are dissected away; a subtalar joint capsule is opened, and a subtalar joint is exposed. A flap of the bone is separated en bloc with a periosteum, a cortical plate and a spongy bone. The bone fragments are reduced with using a mouth expander with a ratchet. A porous titanium nickelide implant in the form of a hollow octagonal rod filled with an autograft or osteoplastic material is introduced into the bone. There are used two memory-shape brackets made of an L-plate a long leg of which has an arched curve and a short leg of which is inclined at 45 degrees and is hook-ended. The long leg of one bracket is introduced into the canal formed through the bone fragment of a calcaneal knot, a median intra-articular fragment and partially through an ankle. A short leg is inserted into a calcaneal knot canal formed below an input of the long leg canal. The long leg of the other bracket is inserted into a canal passing through the calcaneal knot and the bone fragments along a plantar contour of the calcaneal bone, while the leg is inserted into the calcaneal knot. After the bracket strain recovers, the arch of the upper bracket is opened upwards, and the arch of the lower bracket is opened downwards; the hook of the short leg of both brackets is directed and rests from the inside into the cortical plate of the calcaneal knot.

EFFECT: method and device for implementing it provides the durable stabilisation of the bone fragments.

1 ex, 2 cl, 8 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of patients with intraarticular compression calcaneal fractures.

The causes of adverse outcomes of calcaneus osteosynthesis in 24.8-40.5% of cases with compression intraarticular fractures are due to insufficient stabilization and migration of screws through the crushed areas of the cancellous bone, defects filled with hematoma and bone detritus and joint contracture as a result of prolonged immobilization. In addition, the correction of the heel bone shape achieved during the reposition process is disrupted under the influence of functional loads due to the deformation of the regenerate with a weakened structure filling the bone defects. Changes in the shape of the calcaneus lead to the development of deforming arthrosis, flat feet and persistent pain.

A known method for osteosynthesis of the calcaneus with knitting needles, including reposition of fragments on skeletal traction with their subsequent fixation with knitting needles to the bones of the second row of the tarsus, applying a plaster bandage, characterized in that they carry the knitting needle through the inner ankle from above, back and to the outside of the calcaneus, knitting needles at the ankles bend, bite at a distance of 0.5-1 cm and subcutaneously immersed (Patent for the invention of the Russian Federation No. 2285485, IPC A61B 17/58, publ. 20.10.2006).

The disadvantage of this method is the long recovery period of the structure of the calcaneus. Elimination of the displacement of the intra-articular indented fragment by applying skeletal traction is ineffective. Due to swelling of soft tissues and the appearance of conflicts, the use of a plaster cast is contraindicated until they are eliminated. Lack of fixation of the articular platform of the calcaneus, articulating with the talus, can lead to secondary displacement of bone fragments. Long-term immobilization leads to muscle hypotrophy, joint contracture.

A known method of treating calcaneus fractures, including reposition and fixation of fragments, characterized in that the reposition of bone fragments is first carried out using a standard 6.5 mm rod - a screw or Shantz screw inserted from the calcaneal tuber through the calcaneus to its anterior section in the direction a plane parallel to the talacaneal joint, with further fixation by cannulated screws inserted in compression mode (Patent for the invention of the Russian Federation No. 2440046, IPC A61B 17/56, publ. 02.17.2010).

The disadvantage of this method is the lack of replacement of defects in the region of the crushed cancellous bone, which slows the healing time and weakens the resistance of the calcaneus to the effects of functional loads. As a result of pumping and crushing of the intraarticular bone fragment during compression fractures, closed reposition does not allow accurate reposition with restoration of congruency of the articular facets.

A known method of reconstructive osteosynthesis of the calcaneus during an intra-articular compression fracture using a cylindrical implant made of porous titanium nickelide with a through porosity of 60-70% and tightening screws for fixing bone fragments. The essence of the method is as follows. The calcaneus is accessed from the incision that starts above and behind the outer ankle, enveloping it, descends to the plantar surface and ends at the base of the V metatarsal bone. Soft tissues are dissected to the bone with peeling of the plantar flap to the sine of the calcaneus. Tendon cover reclines with exposure of the posterior facet of the subtalar joint. The calcaneal bone fragments are repaired, the bone fragment bearing the articular surface is fixed with a tightening screw to the sustentacular fragment, the resulting bone defect is filled with an implant made of porous titanium nickelide. The wound is sutured. The foot is immobilized with a removable orthosis for 8 weeks (Patent for invention of the Russian Federation No. 2155551, IPC ⁷ A61B 17/56, publ. 09/10/2000, Prokhorenko V.M., Pakhomov I.A., Sadovoy M.A., Kirilova I. A. Experience in the surgical treatment of patients with comminuted transverse articular fractures of the calcaneus with displacement of fragments. Bulletin of traumatology and orthopedics named after N.N. Priorov. No. 3, 2008).

The disadvantages of the method are the lack of fixation of the calcaneal tuber with the possibility of divergence of bone fragments under the influence of the calf muscle, attached by the Achilles tendon to the calcaneal tuber.

Lack of fixation of the intraarticular bone fragment can lead to secondary displacement of fragments, and subsequently to the formation of deforming arthrosis of the calcaneus-joint. Shelter of a porous cylindrical implant with a periosteum damaged by trauma and soft tissues can lead to pressure sores, as well as migration and loss of a structure not fixed in the bone.

Closest to the claimed method is reconstructive osteosynthesis of the calcaneus during an intraarticular compression fracture, including access to the calcaneus, opening the fibrous channels of the tendons of the fibula, moving them up, cutting off the fibula-calcaneus and talus ligament, opening the capsule of the succulent joint damaged calcaneus, creating a sash through which open reposition is carried out, using tools as a lever, restore the length and the height of the heel bone under visual control, an implant made of porous titanium nickel is introduced into the bone defect, the heel bone is fixed with the needles held through bone fragments along the upper articular contour and with the needles held along the lower contour of the calcaneus. If necessary, a fragment of the calcaneal tuber and the intra-articular fragment are fixed at the bone S with alloy brackets with thermomechanical shape memory. “Reconstructive osteosynthesis in intra-articular impression calcaneus fractures” / V.A. Kopysova, V.A. Kaplun, Yu.M. Batrak, A.K. Zhukov, M.N. Petryakov. Bulletin of Traumatology and Orthopedics. N.N. Priorova, 2008, No. 2, pp. 40-43.

The disadvantages of the method are the possibility of early migration of knitting needles held in the spongy damaged bone; the probability of displacement of the calcaneal tuber upward under the influence of the Achilles tendon traction; in the early postoperative period, the need to remove the removable splint to perform manipulations related to dressings and drainage can lead to destabilization of bone fragments; the need to immobilize a plaster cast for at least 2-3 weeks, which limits visual monitoring of the condition of the soft tissues of the lesion area and limits the use of physiotherapeutic treatment; the standing of the spokes over the skin to the fusion of bone fragments within 1.5-2 months can provoke suppuration of soft tissues; the mobility of the implant in the form of a porous rod of a cylindrical shape in the cavity of the bone defect is not excluded, which slows down the growth of bone tissue in the pores of the implant; the absence of dynamic compression between the bone fragments when a gap appears after physiological resorption of the contacting surfaces of the bone fragments can lead to the appearance of mobility and secondary displacement, or the terms of fusion are slowed down.

Known endoprosthesis of the diaphysis of a long tubular bone with a reinforcing rod bifurcated at the end in the form of opposite diverging legs. The reinforcing rod is made of a material with a shape memory effect (Patent for a utility model of the Russian Federation No. 101354, IPC A61F 2/28, published on January 20, 2011, Bull. No. 2).

A reinforcing rod with opposed legs can be used for intraosseous splinting of damaged bones, and opposed legs prevent rotation of the rod inside the bone.

The design drawback is the difficulty of its removal as a result of jamming of the legs in the trabecular bone, the absence of elements providing dynamic compression of bone fragments.

The closest is a bracket having a long wave-like leg, a shoulder and a short leg. The shoulder moves away from the long leg at an angle of 90 °, the short leg moves away from the shoulder at an angle of 90 °, the short leg is directed toward the long leg. Implants with shape memory in traumatology and orthopedics / V.A. Lanshakov, V.E. Gunther, G.L. Plotkin, N.V. Fomichev et al. Tomsk: IAP; NTL Publishing House, 2004, p.66, fig.3.34.

There are no elements providing dynamic compression of bone fragments simultaneously with their splinting.

The objective of the invention is to increase the effectiveness of the treatment of calcaneus during intraarticular compression fractures by unifying the method of open reposition, increasing the stability of stabilization of bone fragments and a porous implant that replaces a bone defect, creating constant uniform compression between the fragments. The review of the articular surface of the calcaneus increases due to the opening of the fibrous channels of the tendons of the fibula muscles, which move up, the fibula-calcaneal and talocaneal ligaments are cut off, the capsule of the subtalar joint is opened and the subtalar joint is exposed. To access the indented fragment (usually including the posterior articular talus surface) from the outside of the calcaneus body in a 2 × 3 cm section, a sash is removed, which is essentially part of the indented fragment, including a periosteum, cortical plate and cancellous bone.

With the help of single-tooth hooks, the displacement of bone fragments along the length is eliminated, while lowering the calcaneal tuber. In the gap between the bone fragments, which, after eliminating the displacement along the length of the calcaneus, increase, the branches of the rotary expander with the cremallera are introduced, the branches are extended to the distance necessary to raise the pressed intraarticular fragment until the anatomical and topographic relationships are completely restored. Behler and Gissare angle indicators are used to control the quality of the reposition. Bone fragments are fixed with temporary Kirschner spokes. A bone defect is plasticized with an implant made of porous titanium nickelide with a through porosity of 60-70%. In accordance with the size of the bone defect, the corresponding implant is selected, which has the shape of an octagonal rod with a channel along the length of the implant, the channel is filled with osteoplastic material or bone chips, and the design is placed in the bone defect below the level of the bone leaflet.

Complete stabilization of bone fragments is carried out by fixing the calcaneal tuber and the intraarticular fragment along the upper contour of the calcaneus, and then the bone fragments along the plantar contour of the calcaneus using the L-shaped staple with shape memory effect. The bracket is made of a plate with a thickness of 2.0 mm and a width of 3.0 mm in the form of a L-shaped figure with a long leg with an arched bend and a short leg mounted to the shoulder at an angle of 45 ° with a hook at the end.

The bracket is installed as follows. At the level of the upper pole of the calcaneal tuber, 7.0-10.0 mm above the line of its fracture (of the duck beak type) or at the level of attachment of the Achilles tendon in the absence of a bone fragment of the calcaneal tubercle, a channel passing through the calcaneal tubercle forms the median intraarticular bone fragment with partial penetration into the talus. 7.0-10.0 mm below the fracture line or below the inlet in the channel of the long leg of the L-shaped bracket is used to form the inlet and channel for the short leg of the bracket, the direction of which in the calcaneal tubercle corresponds to the short leg. Under the long leg of the second L-shaped bracket, a channel is formed that runs parallel and along the plantar contour of the calcaneus with the introduction into the cuboid bone. Above 7.0-10.0 mm of the inlet to the channel under the long leg, a channel under the short leg is formed.

Before installation, the bracket is cooled with a refrigerant to a temperature of 0 ÷ 5 ° C. The long leg of the bracket is straightened, the shoulder of the bracket is set with respect to the long leg at an angle of 90 °, and the short leg and hook at its end are straightened. First of all, the upper bracket is installed, introducing the long and short legs into the prepared channels. The bend arc of the long leg is open up. Then the lower bracket is installed, the arc of the bend of the long leg is directed downward. Upon contact warming with tissues, the bracket takes its original shape. At the same time, the arcuate curved long leg of the bracket, acting as a lever, prevents the “sagging” of the articular facet of the median bone fragment. The short leg of the coracoid staple, resting in the form of a hook against the cortical plate of the calcaneal tuber, prevents it from moving upward, acting in conjunction with the legs of the L-shaped bracket, prevents the fragments from diverging in length. The arcuate curved long leg of the staple, installed parallel and along the plantar contour of the calcaneus with a bend open to the bottom, being a stop for the implant made of porous titanium nickelide, prevents subsidence of the intraarticular fragments and the implant, and the calcaneus remains in shape. After fixing the bone fragments, the slit-like defects between the walls of the implant and the bone are filled with osteoplastic material, bone chips, the implant is closed with a bone leaf. Check the strength of fixation of bone fragments by movements of the foot in various directions. If necessary, a spoke is placed under and along the joint facet of the calcaneus, which is removed after 7-14 days, the sash is fixed with one or two S-shaped staples with a shape memory effect. The periarticular tissues of the calcaneus-talar joint are restored, and active drainage is applied. The wound is sutured.

To ensure rest for the healing period of the damaged ligamentous ligamentous apparatus for 7-10 days, external immobilization is performed with a removable orthosis. Movement in the joints of the foot, ankle with a gradual increase in the range of motion is allowed 14 days after surgery, axial load - after 7-8 weeks.

The novelty of the proposed method for the surgical treatment of intraarticular compression fractures of the calcaneus, staples and implant for its implementation:

1. The valve, formed to reposition bone fragments and placement into the defect of the porous implant, includes the periosteum, cortical plate and spongy bone, which allows you to fully cover the implant, to eliminate the likelihood of leaf necrosis, pressure sores of soft tissues.

2. The use of a rotary expander with a rack for lifting the intraarticular fragment of the calcaneus, reposition along the length and height allows using the dilution of the flattened branches of the rotator to reduce the articular facet by means of its handles, to avoid crushing, splitting of bone fragments during manipulations.

3. The introduction of temporary knitting needles after reposition through bone fragments of the calcaneus along the articular facet and along the plantar contour into the bones of the second row of the tarsus, as well as through the calcaneal tuber, the intraarticular bone fragment into the talus, avoids displacement during plastic replacement of the bone defect and performs osteosynthesis with braces .

4. Unlike simultaneous compression between the bone fragments of the calcaneus when they are fixed with screws, plates, knitting needles, the intraosseous osteosynthesis by the proposed L-shaped staples with the shape memory effect provides dynamic compression and splinting of the bone fragments of the calcaneus, excluding the separation between the fragments during the formation of the regenerate, and their stable position before fusion.

5. The octagonal shape of the porous implant, in contrast to the known cylindrical, without significantly reducing the area of contact with the walls of the bone defect, reduces the mobility of the implant by abutting the faces of the implant.

6. In contrast to the known implant in the form of a cylindrical porous rod inside and along the proposed implant has a channel that serves as a reservoir for a bone graft or osteoplastic material, and if necessary, an additional fixative, for example, a knitting needle or screw, can be inserted through the bone fragments and the channel.

7. The L-shaped bracket for intraosseous osteosynthesis of the calcaneus has a long leg with an arcuate bend, with the help of which longitudinal fixation of the calcaneus is carried out, and a short leg mounted to the shoulder at an angle of 45 ° with a hook on the end, which, resting against the inside of the cortical plate calcaneal tuber, increases the degree of stabilization of bone fragments, due to which compression is achieved.

8. The shoulder of the L-shaped bracket, located on the osseous, when the structure is removed, allows you to easily remove the long and short leg of the bracket from the bone by grabbing it, for example with a single-tooth hook and traction.

The proposed method for surgical treatment of intra-articular compression fractures of the calcaneus, the brace and implant for its implementation are characterized in that after the exposure of the damaged calcaneus 1 along the fracture lines of the medial subarticular bone fragment as a single unit, including the periosteum, cortical plate and cancellous bone, the sash 2 is removed (Fig. .one). With the help of single-tooth hooks, the displacement along the length of the calcaneus is eliminated, the branches 3 of the rotary expander with the cremallera are introduced into the gap between the bone fragments, when moving apart, the displacement along the height of the calcaneus 1 is eliminated, and the displacement along the length is corrected (Figure 2). After anatomically accurate reposition, the calcaneus is temporarily fixed by 1 with three Kirschner spokes 3, 4, 5, one of which 3 is carried out through fragments along the articular facet, the other 4 along the plantar contour of the calcaneus, and the third 5 through the calcaneal tubercle 6, intraarticular fragment in the talus 7. A porous implant 8 is placed in the bone defect (Figure 3). The final stabilization of bone fragments is carried out using two staples with a memory of form 9, 10. For their installation, channels are formed, one of which is performed through the calcaneal tubercle 6, an intraarticular fragment is inserted into the talus 7, and the second canal is inserted through the calcaneal tubercle 6 along the plantar the contour of the calcaneus in the cuboid bone 11 (Figure 4).

In order to fix and dynamically compress bone fragments of the calcaneus from a plate of titanium nickelide having a shape memory effect, a bracket was created in the form of a L-shaped figure with a long leg 12, which through shoulder 13 passes into a short leg 14. The long leg 12 has a bend 15, the arc of which is facing the short leg 14, and the short leg is set at an angle of 45 ° to the long leg, and its end is bent in the form of a hook 16 (Figure 5). To replace a bone defect, an implant made of porous titanium nickelide in the form of an octagonal rod having a hollow through hole 17 was created. Eight faces of the implant 18, abutting the surrounding bone, reduce the likelihood of its mobility, without significantly reducing the contact area of the implant with the surrounding bone. The internal channel 19 along the porous implant, if necessary, allows for additional fixation of bone fragments and implants by means of a spoke or rod and use the channel as a container for bone graft or osteoplastic material, thus providing the most favorable conditions for growing into the pores of the implant bone tissue, excludes the possibility of subsidence of the intraarticular fragment under axial loads (Fig.6, Fig.7).

Example 1. Patient K., 43 years old, fell from a height of about 6 meters. The ambulance team was delivered to the emergency room. After examination and X-ray examination, the diagnosis was established: closed intraarticular comminuted comminuted impression fracture of the left calcaneus with displacement of fragments (Fig. 8). Under general anesthesia, an operation was performed: open reposition and osteosynthesis of the left calcaneus with a blocking bracket with shape memory effect, plastic bone defect with a porous implant. In connection with the split of the calcaneus in two planes, the three-spoke blocking bracket is held along the upper contour, and the lower arch is strengthened. In this case, the porous implant received a reliable support. Wound drainage with active aspiration during the day. Primary healing. External immobilization was stopped after 8 weeks. After 4 months, upon examination, the patient makes no complaints, walks, fully loading the injured foot, its arch is restored to normal (the Beler’s heel bone angle is 40 °).

Claims (2)

1. A method for surgical treatment of an intra-articular compression fracture of the calcaneus, including access to the calcaneus, opening the fibrous ducts of the tendons of the fibula, moving them upward, cutting off the fibula-calcaneum and talocaneal ligament, opening the capsule of the subtalar joint and exposing the calcareous joint, bones, the creation of a sash through which an open reposition is carried out, using tools as a lever, restore the length and height of the calcaneus under the visual with a troll, a porous titanium nickelide implant is inserted into the bone defect, the calcaneus is fixed with the needles held through bone fragments along the upper articular contour, and the bone fragments are fixed with the needles along the lower calcaneus contour, the bone fragments are stabilized by alloy brackets with thermomechanical shape memory, characterized in that the bone leaf is isolated in a single block with the periosteum, cortical plate and cancellous bone, bone fragments are repositioned using a rotary expander with a cremallera, placed a porous titanium nickelide plantate in the form of a hollow octagonal rod filled with an autograft or osteoplastic material, two staples according to claim 2 are used for osteosynthesis, the long leg of one staple being inserted into a canal formed through a bone fragment of the calcaneal tuber, the median intraarticular bone fragment and partially the talus, and a short leg is inserted into the channel of the calcaneal tuber, formed below the inlet of the channel for the long leg, the long leg of the other bracket is inserted into the channel passing through mountains of the calcaneus and bone fragments along the plantar contour of the calcaneus, and the short leg is inserted into the calcaneal tubercle; in this case, after the staple is restored, the arch of the bend of the long leg of the upper staple is open upward, the lower one is downward, and the hook of the short leg of both staples is directed and abuts against the inside of the cortical calcaneal tuber plate. 2. A bracket for osteosynthesis, including long and short legs connected by a shoulder, characterized in that it is made of a plate with a shape memory effect in the form of an L-shaped figure, the long leg has an arched bend, a short leg is installed to the shoulder at an angle of 45 ° and has a hook at the end.

Images