RU2177271C2 - Method for performing transosseous fixation of intra- and extramedullary bone transplants in treating false articulations - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves skeletting both bone fragments on one side only. Three holes are drilled on one line. Two of them belong to the same bone fragment and the third one to the other fragment. The drilled fragments are laid on external and external side of the cortical plate of both reposed fragments. Catgut ligature is brought through one of the peripheral holes inside. The ligature is brought outside through the middle hole and back forming in this way an extracortical loop. The ligature is extracortically brought through the created loop to return to the initial hole. The ligature is tied. EFFECT: enhanced reliability in fixing transplants. 2 dwg

Description

 The invention relates to medicine, namely to orthopedics and traumatology, i.e. to methods of bone grafting.

 There are many analogues of bone grafting with replacement, support, and osteoinductive purpose in the treatment of patients with false joints and bone defects (Radzimovsky I.V., 1881; Petrov N.N., 1913; Chaklin V.D., 1932: Shulutko L.I. ., 1948: Volkov M.V., 1967; Ollier, 1867; Lexer, 1908; Juder J., 1965 and others).

As a prototype of the invention, we took intra- and extramedullary bone grafting indicated in the work of I. A. Movshovich (1994). The osteoplasty described by him is aimed at creating optimal conditions for both bone tissue biology (by stimulating weakened osteogenesis) and ensuring mechanical stability of bone fragments due to the tight insertion of the bone pin into the bone marrow canal (Fig. 1 a, b). However, in our opinion, there are a number of significant drawbacks that significantly limit the indications for this method of treating false joints, which include the following:
1) for the fixation of the bone graft, it is necessary to skeletonize bone fragments for a considerable period of time, which is inevitably accompanied by a decrease in the vascularization of the fracture zone or the false joint, and therefore, inhibition of periosteal osteogenesis;
2) fixation of the bone graft to the bed with catgut cerclage is not reliable enough and does not ensure their tight mutual adaptation. This is due to the fact that cerclage has no other protection factors from slipping the ligature above or below the graft, except for the significant tension that creates a link between the inner surface of the ligature and the outer surface of the bone fragments with the bone graft. But this tension is not unchanged: its degree decreases over time - both due to relaxation of the knot and due to colloidal swelling of the catgut in a humid environment;
3) a tight mutual adaptation between the intramedullary graft and the bone marrow canal of both bone fragments can be achieved only by obstruction of the bone marrow canal, and therefore, at the cost of turning off endosteal ossification. The role of the latter, however, is very important both in the early and especially in the late stages of osteogenesis.

 Our proposed method for transossal fixation of intra- and extramedullary bone grafts is free from the above disadvantages.

 The essence of the method is as follows. After the opening of the fracture zone or the false joint, the ends of the bone fragments are refreshed, and they are skeletonized only from the side where it is supposed to place an extramedullary graft. In this case, the periosteum is longitudinally dissected and economically separated to the sides to the width of the placed bone graft. Three perforations are drilled along the periosteum dissection line with a drill with a diameter of 2.8-3.5 mm so that two of them are located on one bone fragment and one on the other (Fig. 2a). The distance between the extreme openings is 0.3-1.5 cm longer than the length of the extramedullary and intramedullary grafts inserted into the marrow canal. The latter is obtained by resection of the tibial crest site. The size of the grafts may vary depending on the nature and extent of the false joint. In the middle of the obtained grafts, one hole is also drilled. The grafts are placed on the inner and outer sides of the cortical plate of both repaired bone fragments and transosseously fixed with one catgut ligature, drawn through previously drilled holes as follows (Fig. 2b). Through one of the two peripheral openings, the end of the catgut suture is drawn externally into the medullary canal and is brought out through the middle opening from the inside out and back. In this case, an extracortical loop is formed. Next, the end of the thread is brought out extracortically and passed through the loop formed, returning to the initial hole, where it is tied (Fig. 2c). At the same time, the zone of the pseudoarthrosis is overlapped by cortical-spongy autografts extra- and intramedullary on one side of the exposed side. Reliable fixation and tight adaptation of transplants to the bed is achieved without circular skeletonization of fragments and obstruction of the bone marrow cavity. In addition to providing greater mechanical reliability of fixation of the transplants and maintaining vascularization of bone fragments, the proposed method is a factor in the biological stimulation of reparative regeneration due to osteoperforation of the pseudoarthrosis and the presence of catgut in it. The latter, having a protein nature, causes some weakened reaction locally, thereby contributing to the activation of osteogenesis.

Features:
1) the skeletalization of bone fragments is carried out monolaterally - from the expanned side and only to the width of the placed bone graft;
2) on both bone fragments along the dissection line of the periosteum, three holes are drilled;
3) the intramedullary graft does not completely obstruct the bone marrow canal;
4) the fixation of the transplants is carried out by one ligature.

 As an example of the clinical application of the proposed method, the following observation.

 Patient P., 27 years old, was admitted to the orthopedic department of the RTC on 01.21.96 with a diagnosis of False joint of the middle third of the tibia of the left leg. From the anamnesis: on April 9, 1995, as a result of a traffic accident, an open comminuted fracture of both bones of the middle third of the left tibia occurred with a displacement. For three weeks, the patient was on skeletal traction for the calcaneus in the trauma department of the city hospital in Kizilyurt, where the operation was performed on April 27, 95: Extra-focal osteosynthesis of the left lower leg bones with the Ilizarov apparatus. In connection with suppuration of soft tissues and development of spoke osteomyelitis, in the absence of signs of fracture fusion, the Ilizarov apparatus was removed and a gypsum dressing was applied.

 On the control roentgenograms of the left lower leg of 01/13/96, signs of the formed false joint of the tibia with sclerotherapy of the ends of the bone fragments and the formation of locking plates are noted.

 01/24/96 the operation was performed: Extra-focal osteosynthesis of the bones of the left lower leg with the Ilizarov apparatus with intra- and extramedullary autoplasty of the false joint of the tibia and osteotomy of the fibula.

 Under endotracheal anesthesia in the patient’s position on the back, a longitudinal skin incision was made 1 cm outward from the tibial crest at the level of the middle third of the leg with a length of 12 cm. The sharp and blunt path of the pseudoarthrosis was relieved of soft tissues with excision of fibro-altered interfragmental tissues. The narrowing of the bone marrow canals at the ends of the fragments of the tibia is eliminated. The periosteum of both fragments is longitudinally dissected for 1.5 cm. With a drill, 3.1 mm in diameter, along the periosteum dissection line at a distance of 3.5 cm from the ends of both fragments, one hole was drilled and another hole was retreating 1 cm from the edge of one of the fragments.

 An oblique transverse osteotomy of the fibula was made from a separate section, 2 cm long, along the outer surface of the lower leg.

 The next stage of the operation was the taking of autografts from the tibial crest in the proximal metadiaphyseal part. Prepared grafts measuring 6.0 cm by 2.5 cm by 1.0 cm were drilled with the same drill in the middle, placed intra- and extramedullary and fixed with one catgut ligature. The method of ligature is shown in Figure 2. The periosteum, separated to the sides, is laid on the extramedullary graft, partially covering it from the sides. Stitches are sutured to the skin. A typical extra focal osteosynthesis of the left tibia with an Ilizarov apparatus of four rings was performed.

 The wounds healed by primary intention. For outpatient treatment, the patient was discharged 02/12/96 with a recommendation to give a metered axial load on the left leg.

 On the control radiographs of the left lower leg of 05/18/96, signs of graft engraftment and consolidation of the pseudoarthrosis are noted: smooth contours and partial transformation of autografts with the disappearance of the inter-fragment gap; the lumen of the bone marrow canal is not broken. The Ilizarov apparatus after a clinical test was dismantled. The result of treatment is regarded by us as good.

 Thus, the proposed invention "A method for transossal fixation of intra- and extramedullary bone grafts in the treatment of pseudoarthrosis" in our opinion is optimal and more pathogenetically substantiated in comparison with the prototype, which allows to reduce the time and improve the results of treatment of patients with false joints of tubular bones.

Claims (1)

 A method for trans-fixation of intra- and extramedullary bone grafts in the treatment of pseudoarthrosis, including laying of grafts, characterized in that both bone fragments are skeletonized only on one side, three holes are drilled on one line, two of which are laid on one fragment and one on the other drilled grafts from the inner and outer sides of the cortical plate of both repaired bone fragments are carried out through one of the two peripheral openings catgut ligature outside inside, withdraw the ligature through the middle hole from the inside out and back, forming an extracortical loop, remove the ligature extracortically and pass through the formed loop, returning to the original hole, tie the ligature.

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