MD1033Z - Method for surgical treatment of pelvic fractures associated with sigmoid and/or straight intestine injury - Google Patents
Method for surgical treatment of pelvic fractures associated with sigmoid and/or straight intestine injury Download PDFInfo
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- MD1033Z MD1033Z MDS20150110A MDS20150110A MD1033Z MD 1033 Z MD1033 Z MD 1033Z MD S20150110 A MDS20150110 A MD S20150110A MD S20150110 A MDS20150110 A MD S20150110A MD 1033 Z MD1033 Z MD 1033Z
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- sigmoid
- intestine
- colostomy
- pelvic
- fixation
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- 210000000936 intestine Anatomy 0.000 title claims abstract description 20
- 208000027418 Wounds and injury Diseases 0.000 title claims abstract description 15
- 230000006378 damage Effects 0.000 title claims abstract description 13
- 208000014674 injury Diseases 0.000 title claims abstract description 13
- 238000001356 surgical procedure Methods 0.000 title claims abstract description 11
- 238000000034 method Methods 0.000 title claims description 11
- 206010034246 Pelvic fractures Diseases 0.000 title abstract description 3
- 210000003049 pelvic bone Anatomy 0.000 claims abstract description 23
- 210000000683 abdominal cavity Anatomy 0.000 claims abstract description 10
- 239000012634 fragment Substances 0.000 claims abstract description 10
- 210000004197 pelvis Anatomy 0.000 claims abstract description 8
- 206010052428 Wound Diseases 0.000 claims abstract description 7
- 210000003205 muscle Anatomy 0.000 claims abstract description 6
- 210000001139 rectus abdominis Anatomy 0.000 claims abstract description 6
- 210000003815 abdominal wall Anatomy 0.000 claims abstract description 5
- 230000006978 adaptation Effects 0.000 claims abstract description 5
- 238000002695 general anesthesia Methods 0.000 claims abstract description 5
- 238000002350 laparotomy Methods 0.000 claims abstract description 5
- 210000000664 rectum Anatomy 0.000 claims description 12
- 208000010392 Bone Fractures Diseases 0.000 claims description 11
- 230000000968 intestinal effect Effects 0.000 claims description 4
- 230000001483 mobilizing effect Effects 0.000 claims description 2
- 239000003814 drug Substances 0.000 abstract description 4
- 230000001681 protective effect Effects 0.000 abstract 1
- 206010017076 Fracture Diseases 0.000 description 7
- 230000008733 trauma Effects 0.000 description 5
- 210000000988 bone and bone Anatomy 0.000 description 4
- 238000007596 consolidation process Methods 0.000 description 4
- 210000001696 pelvic girdle Anatomy 0.000 description 4
- 238000011161 development Methods 0.000 description 3
- 238000012545 processing Methods 0.000 description 3
- 229940079593 drug Drugs 0.000 description 2
- 230000002550 fecal effect Effects 0.000 description 2
- 208000015181 infectious disease Diseases 0.000 description 2
- 238000009434 installation Methods 0.000 description 2
- 239000011505 plaster Substances 0.000 description 2
- 238000002271 resection Methods 0.000 description 2
- 210000004872 soft tissue Anatomy 0.000 description 2
- 238000011477 surgical intervention Methods 0.000 description 2
- 210000001519 tissue Anatomy 0.000 description 2
- 208000007333 Brain Concussion Diseases 0.000 description 1
- 208000004221 Multiple Trauma Diseases 0.000 description 1
- 208000023637 Multiple injury Diseases 0.000 description 1
- 206010054828 Rectal lesion Diseases 0.000 description 1
- 206010044541 Traumatic shock Diseases 0.000 description 1
- 210000001015 abdomen Anatomy 0.000 description 1
- 230000002421 anti-septic effect Effects 0.000 description 1
- 230000000703 anti-shock Effects 0.000 description 1
- 230000015572 biosynthetic process Effects 0.000 description 1
- 210000000038 chest Anatomy 0.000 description 1
- 230000006835 compression Effects 0.000 description 1
- 238000007906 compression Methods 0.000 description 1
- 230000002596 correlated effect Effects 0.000 description 1
- 230000006837 decompression Effects 0.000 description 1
- 238000003745 diagnosis Methods 0.000 description 1
- 201000010099 disease Diseases 0.000 description 1
- 208000037265 diseases, disorders, signs and symptoms Diseases 0.000 description 1
- 230000023597 hemostasis Effects 0.000 description 1
- 210000001621 ilium bone Anatomy 0.000 description 1
- 238000003780 insertion Methods 0.000 description 1
- 230000037431 insertion Effects 0.000 description 1
- 210000002429 large intestine Anatomy 0.000 description 1
- 230000003902 lesion Effects 0.000 description 1
- 239000000463 material Substances 0.000 description 1
- 210000002346 musculoskeletal system Anatomy 0.000 description 1
- 230000002980 postoperative effect Effects 0.000 description 1
- 208000011580 syndromic disease Diseases 0.000 description 1
- 210000000689 upper leg Anatomy 0.000 description 1
- 230000000007 visual effect Effects 0.000 description 1
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Abstract
Description
Invenţia se referă la medicină, în special la chirurgie şi poate fi folosită pentru tratamentul chirurgical al fracturilor oaselor bazinului asociate cu lezarea intestinului sigmoid şi/sau rect. The invention relates to medicine, in particular to surgery and can be used for the surgical treatment of pelvic bone fractures associated with injury to the sigmoid intestine and/or rectum.
Este cunoscută metoda de tratament al leziunilor rectului prin instituirea colostomei de degajare - operaţia Hartman, prin care se rezecă partea inferioară a sigmoidului şi rectului, cu închiderea bontului rectal şi aducerea porţiunii proximale în colostomie iliacă stângă terminală [1]. The method of treating rectal lesions by establishing a relief colostomy is known - the Hartman operation, which resects the lower part of the sigmoid and rectum, closing the rectal stump and bringing the proximal portion into the terminal left iliac colostomy [1].
Există un dispozitiv de fixare externă în fracturile oaselor bazinului, care include introducerea elementelor de fixare în cristele iliace şi fixarea lor de suporturile pelviene. Dispozitivul este dotat cu două suporturi pentru oasele bazinului din material roentgen negativ cu caneluri în formă de sector de arc cu raza de 90…110°, iar porţiunea anterioară este executată în formă de unghi drept, suporturile fiind fixate de oasele bazinului cu ajutorul unor tije îndoite la capătul funcţional şi executate în formă de tirbuşon, iar capetele opuse ale tijelor sunt unite cu suporturile cu ajutorul unor elemente de fixare. La capătul anterior al suporturilor sunt instalate tije filetate cu gradaţii care sunt reglate cu ajutorul unor piuliţe pentru repoziţia arcului anterior al bazinului. Suplimentar la capătul posterior sunt montate sprijine pentru o bară telescopică gradată, care este reglată cu ajutorul unei piuliţe şi este destinată pentru repoziţia arcului posterior al bazinului, un suport femural în formă de sector de arc, care are un şurub de blocare şi un element de fixare pe os. Totodată, suportul femural este fixat cu ajutorul a două tije filetate dotate şi cu câte două piuliţe la un capăt, iar capetele opuse se unesc de unul din suporturile pentru oasele bazinului cu ajutorul unor noduri de fixare. There is an external fixation device for pelvic bone fractures, which includes the insertion of fixation elements into the iliac crests and their fixation to pelvic supports. The device is equipped with two pelvic bone supports made of radiopaque material with arc-shaped grooves with a radius of 90…110°, and the anterior portion is made in the form of a right angle, the supports being fixed to the pelvic bones by means of rods bent at the functional end and made in the shape of a corkscrew, and the opposite ends of the rods are connected to the supports by means of fixation elements. At the anterior end of the supports, threaded rods with graduations are installed, which are adjusted by means of nuts for the repositioning of the anterior arch of the pelvis. Additionally, at the posterior end, supports are mounted for a graduated telescopic bar, which is adjusted with a nut and is intended for repositioning the posterior arch of the pelvis, a femoral support in the form of an arc sector, which has a locking screw and a fixing element on the bone. At the same time, the femoral support is fixed with the help of two threaded rods equipped with two nuts at one end, and the opposite ends are joined to one of the supports for the pelvic bones with the help of fixing nodes.
După prelucrarea câmpului operator cu o soluţie antiseptică, prin creastă, în oasele iliace ale bazinului, se introduc tijele, se fixează cu ajutorul elementelor de fixare de placa suportului bazinului. Cu ajutorul tijelor filetate cu gradaţii se efectuează repoziţia închisă a fragmentelor arcului anterior al bazinului. Controlul asupra poziţiei fragmentelor se realizează conform diviziunilor metrice şi se corelează cu datele roentgenogramelor. Repoziţia şi compresiunea dintre fragmentele arcului posterior se realizează cu ajutorul ramei în U, pe calea rotaţiei piuliţei de reglare în timpul controlului vizual concomitent asupra fragmentelor cu ajutorul riglei metrice şi a indicatorului. Apoi în zona subtrohanteriană a femurului pe partea leziunii se introduce elementul fixator, se instalează în canelura carcasei şi se fixează cu un şurub de blocare. Carcasa suportului femural se uneşte cu suportul bazinului cu ajutorul tijelor cu filet în direcţie laterală, se efectuează decompresiunea articulaţiei, se pozează în regim de fixare până la formarea concrescenţei osoase a fracturilor [2]. After processing the operating field with an antiseptic solution, through the ridge, in the iliac bones of the pelvis, rods are inserted, fixed with the help of fixing elements to the pelvic support plate. Using threaded rods with graduations, closed reposition of the fragments of the anterior arch of the pelvis is performed. Control over the position of the fragments is carried out according to metric divisions and is correlated with the data of the roentgenograms. Reposition and compression between the fragments of the posterior arch is carried out using the U-frame, by rotating the adjusting nut during simultaneous visual control of the fragments using the metric ruler and the indicator. Then, the fixing element is inserted into the subtrochanteric area of the femur on the side of the lesion, installed in the groove of the casing and fixed with a locking screw. The femoral support housing is connected to the pelvic support using threaded rods in the lateral direction, the joint is decompressed, and the patient is placed in a fixation mode until the bone congrowth of the fractures is formed [2].
În calitate de cea mai apropiată soluţie este cunoscută metoda de tratament chirurgical al pacienţilor cu traume asociate, şi anume cu fracturi ale oaselor bazinului cu lezarea intestinului sigmoid sau rectului, unde se instituie colostoma de degajare din intestinul sigmoid, consolidarea oaselor bazinului are la 34…48 zile de tratament după aplicarea atelelor ghipsate şi amplasarea în poziţie pentru consolidarea oaselor bazinului [3]. As the closest solution, the surgical treatment method of patients with associated trauma, namely with fractures of the pelvic bones with damage to the sigmoid intestine or rectum, is known, where a colostomy is established to drain the sigmoid intestine, and the consolidation of the pelvic bones occurs after 34…48 days of treatment after the application of plaster splints and placement in position for consolidation of the pelvic bones [3].
Dezavantajele metodelor cunoscute sunt: în cazul fracturilor bazinului asociate cu lezarea intestinului sigmoid şi/sau rect utilizarea acestor metode este limitată de dificultăţi la introducerea elementelor de fixare în oasele pelviene, există riscul infectării ţesuturilor în jurul broşelor din cauza apropierii colostomei în regiunea iliacă stângă, folosirea atelelor ghipsate şi a poziţiilor de amplasare a pacienţilor cu fracturi ale oaselor bazinului prelungeşte perioada de tratament cu apariţia complicaţiilor la consolidarea oaselor. The disadvantages of the known methods are: in the case of pelvic fractures associated with damage to the sigmoid intestine and/or rectum, the use of these methods is limited by difficulties in introducing the fixing elements into the pelvic bones, there is a risk of infection of the tissues around the pins due to the proximity of the colostomy to the left iliac region, the use of plaster splints and positioning of patients with pelvic bone fractures prolongs the treatment period with the appearance of complications during bone consolidation.
Problema pe care o rezolvă invenţia dată constă în elaborarea unei metode de tratament chirurgical al fracturilor oaselor bazinului asociate cu lezarea intestinului sigmoid şi/sau rect, care include instituirea colostomei de degajare în hipocondrul stâng, lateral de muşchiul rect al abdomenului, introducerea elementelor de fixare la nivelul cristelor iliace, montarea dispozitivului de fixare externă a bazinului cu reducerea dozată a fragmentelor oaselor pelviene până la adaptarea lor deplină. The problem solved by this invention consists in developing a method for surgical treatment of pelvic bone fractures associated with damage to the sigmoid intestine and/or rectum, which includes establishing a relief colostomy in the left hypochondrium, lateral to the rectus abdominis muscle, introducing fixation elements at the level of the iliac crests, mounting the external pelvic fixation device with dosed reduction of the pelvic bone fragments until their full adaptation.
Esenţa invenţiei constă în aceea că se efectuează anestezia generală, laparotomia mediană, revizia cavităţii abdominale, se mobilizează intestinul sigmoid, se rezecă segmentul de intestin lezat, se formează bontul rectal cu fixarea lui de peretele abdominal anterior, se efectuează o incizie în regiunea hipocondrului stâng, cu 1,5 cm lateral de muşchiul rect al abdomenului, se creează condiţii optimale pentru funcţionarea colostomei, se exteriorizează capătul distal al intestinului sigmoid şi se instituie colostoma de degajare, apoi se introduc tije de fixare la nivelul cristelor iliace, care se montează la sistemul de fixare externă a bazinului, după care se efectuează repoziţia dozată a fragmentelor oaselor pelviene până la adaptarea lor deplină, se drenează cavitatea abdominală şi se suturează plaga pe straturi. The essence of the invention consists in performing general anesthesia, median laparotomy, revision of the abdominal cavity, mobilizing the sigmoid intestine, resecting the injured intestinal segment, forming the rectal stump with its fixation to the anterior abdominal wall, making an incision in the left hypochondrium region, 1.5 cm lateral to the rectus abdominis muscle, creating optimal conditions for the functioning of the colostomy, exteriorizing the distal end of the sigmoid intestine and establishing the release colostomy, then inserting fixation rods at the level of the iliac crests, which are mounted to the external fixation system of the pelvis, after which the dosed repositioning of the pelvic bone fragments is performed until their full adaptation, draining the abdominal cavity and suturing the wound in layers.
Avantajul metodei propuse de tratament chirurgical al fracturilor oaselor bazinului asociate cu lezarea sigmoidului şi/sau rectului este delimitarea anatomică obţinută între zonele de intervenţie chirurgicală, ce previne dezvoltarea "sindromului de agravare reciprocă", permite fixarea stabilă a inelului pelvian, face posibilă conduita aseptică pe toată perioada de consolidare a fracturii, uşurează munca chirurgului de prelucrare a ţesuturilor în jurul colostomei, asigură instalarea şi schimbarea colectorului de mase fecale, manipularea dispozitivului de fixare externă a oaselor bazinului, precum şi posibilitatea efectuării reducerii repetate a fragmentelor osoase, previne dezvoltarea complicaţiilor, mobilizarea precoce a pacienţilor semnificativ micşorează perioada de tratament, restabileşte mai repede pasajul intestinal şi ameliorează rezultatele în cazuri foarte dificile. The advantage of the proposed method of surgical treatment of pelvic bone fractures associated with damage to the sigmoid and/or rectum is the anatomical delimitation obtained between the areas of surgical intervention, which prevents the development of the "mutual aggravation syndrome", allows stable fixation of the pelvic ring, makes aseptic conduct possible throughout the period of fracture consolidation, facilitates the surgeon's work of processing tissues around the colostomy, ensures the installation and change of the fecal mass collector, manipulation of the external fixation device of the pelvic bones, as well as the possibility of performing repeated reduction of bone fragments, prevents the development of complications, early mobilization of patients significantly shortens the treatment period, restores intestinal passage faster and improves results in very difficult cases.
Metoda propusă este minim invazivă, operativă, efectivă, necostisitoare şi, cel mai important, previne dezvoltarea complicaţiilor legate de instituirea colostomei în regiunea iliacă în apropierea elementelor de fixare. The proposed method is minimally invasive, operative, effective, inexpensive and, most importantly, prevents the development of complications related to the establishment of a colostomy in the iliac region near the fixation elements.
Metoda se realizează în modul următor: se efectuează anestezia generală, laparotomia mediană, revizia cavităţii abdominale, se mobilizează intestinul sigmoid, se rezecă segmentul de intestin lezat, se formează bontul rectal cu fixarea lui de peretele abdominal anterior, se efectuează o incizie în regiunea hipocondrului stâng, cu 1,5 cm lateral de muşchiul rect al abdomenului, se creează condiţii optimale pentru funcţionarea colostomei, se exteriorizează capătul distal al intestinului sigmoid şi se instituie colostoma de degajare, apoi se introduc tije de fixare la nivelul cristelor iliace, care se montează la sistemul de fixare externă a bazinului, după care se efectuează repoziţia dozată a fragmentelor oaselor pelviene până la adaptarea lor deplină, se drenează cavitatea abdominală şi se suturează plaga pe straturi. The method is performed as follows: general anesthesia, median laparotomy, revision of the abdominal cavity, mobilization of the sigmoid intestine, resection of the injured intestinal segment, formation of the rectal stump with its fixation to the anterior abdominal wall, an incision is made in the left hypochondrium region, 1.5 cm lateral to the rectus abdominis muscle, optimal conditions for the functioning of the colostomy are created, the distal end of the sigmoid intestine is exteriorized and the release colostomy is established, then fixation rods are inserted at the level of the iliac crests, which are mounted to the external fixation system of the pelvis, after which the dosed repositioning of the pelvic bone fragments is performed until their full adaptation, the abdominal cavity is drained and the wound is sutured in layers.
Exemplul 1 Example 1
Pacientul M., în vârstă de 23 ani, a fost internat cu diagnosticul: politraumatism, comoţie cerebrală, traumă închisă a cutiei toracice, fracturi ale coastelor 5-6 pe stânga, traumă închisă a abdomenului, fractura oaselor bazinului tip C, lezarea segmentului recto-sigmoid al intestinului gros, şoc traumatic gr. II. S-au efectuat măsuri antişoc şi examinarea completă. S-a efectuat anestezia generală, prelucrarea câmpului operator, laparotomia mediană, revizia cavităţii abdominale, hemostaza. S-a depistat lezarea rectului cu marginile zdrobite ale plăgii. S-a efectuat desecarea rectului deasupra locului de traumatizare, rezecţia segmentului lezat. Bontul rectal s-a suturat şi fixat de peretele abdominal anterior. Intestinul sigmoid a fost mobilizat. S-a efectuat o incizie în regiunea hipocondrului stâng, cu 1,5 cm lateral de muşchiul rect al abdomenului, a fost exteriorizat capătul intestinului şi instituită colostoma de degajare. Au fost introduse elementele de fixare la nivelul cristelor iliace cu montarea dispozitivului de fixare externă a bazinului, s-a efectuat drenarea cavităţii abdominale şi suturarea plăgii pe straturi, au fost aplicate pansamente aseptice şi s-a conectat colectorul pentru mase fecale. Perioada postoperatorie a decurs dificil, dar complicaţii caracteristice pentru aşa pacienţi - infectarea ţesuturilor moi în jurul broşelor - nu s-au depistat. De la a 3-a zi după operaţie pacientul a fost mobilizat, aşezându-se în pat, peste o săptămână s-a ridicat şi s-a deplasat cu ajutorul cârjelor. Starea ţesuturilor moi în jurul broşelor era satisfăcătoare, colostoma funcţiona fără probleme. După consolidarea fracturilor oaselor bazinului dispozitivul de fixare externă a fost demontat, pacientul a continuat să se deplaseze fără cârje, sigmostoma a fost închisă în termenele recomandate. Utilizarea metodei propuse de tratament chirurgical al fracturilor oaselor bazinului asociate cu lezarea intestinului sigmoid şi/sau rect asigură delimitarea anatomică a zonelor de intervenţie chirurgicală şi permite fixarea stabilă a inelului pelvian cu dispozitivul de fixare externă, conduită aseptică a plăgii pe toată perioada până la consolidarea fracturilor. Patient M., 23 years old, was hospitalized with the diagnosis: polytrauma, cerebral concussion, closed trauma of the thoracic cage, fractures of ribs 5-6 on the left, closed trauma of the abdomen, fracture of the pelvic bones type C, injury of the recto-sigmoid segment of the large intestine, traumatic shock gr. II. Antishock measures and a complete examination were performed. General anesthesia, processing of the operating field, median laparotomy, revision of the abdominal cavity, hemostasis were performed. Injury of the rectum with crushed wound edges was detected. Desiccation of the rectum above the trauma site, resection of the damaged segment were performed. The rectal stump was sutured and fixed to the anterior abdominal wall. The sigmoid intestine was mobilized. An incision was made in the left hypochondrium region, 1.5 cm lateral to the rectus abdominis muscle, the end of the intestine was externalized and a decompression colostomy was established. Fixing elements were introduced at the level of the iliac crests with the installation of the external pelvic fixation device, the abdominal cavity was drained and the wound was sutured in layers, aseptic dressings were applied and the fecal collector was connected. The postoperative period was difficult, but complications characteristic of such patients - infection of the soft tissues around the staples - were not detected. From the 3rd day after the operation, the patient was mobilized, sitting in bed, after a week he got up and moved with the help of crutches. The condition of the soft tissues around the staples was satisfactory, the colostomy functioned without problems. After the pelvic bone fractures were consolidated, the external fixation device was removed, the patient continued to move without crutches, the sigmoidostomy was closed within the recommended time frame. The use of the proposed method of surgical treatment of pelvic bone fractures associated with damage to the sigmoid intestine and/or rectum ensures anatomical delimitation of the areas of surgical intervention and allows for stable fixation of the pelvic ring with the external fixation device, aseptic wound management throughout the period until the fractures are consolidated.
Metoda propusă de tratament chirurgical al fracturilor oaselor bazinului asociate cu lezarea intestinului sigmoid şi/sau rect s-a utilizat în laboratorul şi catedrele USMF şi IMU în trei cazuri la pacienţi cu fracturi ale inelului pelvian şi lezarea sigmoidului sau rectului, obţinându-se rezultate pozitive care corespund cerinţelor necesare: restabileşte inelul pelvian, este minim invazivă şi previne complicaţiile în cazuri grave. The proposed method of surgical treatment of pelvic bone fractures associated with injury to the sigmoid intestine and/or rectum was used in the laboratory and departments of the USMF and IMU in three cases in patients with pelvic ring fractures and injury to the sigmoid or rectum, obtaining positive results that meet the necessary requirements: it restores the pelvic ring, is minimally invasive and prevents complications in serious cases.
1. Кузин М.И. Хирургические болезни. Москва, Медицина, 1986, p. 528-549 1. Kuzin M.I. Surgical diseases. Moscow, Medicine, 1986, p. 528-549
2. MD 2298 F1 2003.11.30 2. MD 2298 F1 2003.11.30
3. Кузнечихин Е.П., Немсадзе B.П. Множественная и сочетанная травма опорно-двигательной системы у детей. Москва, Медицина, 1999, p.194-199 3. Kuznecikhin E.P., Nemsadze B.P. Multiple and combined trauma of the musculoskeletal system in children. Moscow, Medicine, 1999, p.194-199
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| MD2298F1 (en) * | 2003-01-30 | 2003-11-30 | Univ Nicolae Testemitanu | Device for reposition and fixation of pelvic bones |
Non-Patent Citations (2)
| Title |
|---|
| Кузин М.И. Хирургические болезни. Москва, Медицина, 1986, p. 528-549 * |
| Кузнечихин Е.П., Немсадзе B.П. Множественная и сочетанная травма опорно-двигательной системы у детей. Москва, Медицина, 1999, p.194-199 * |
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