RU2180811C2 - Method for elongating femur - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves transcutaneously introducing fixing wires for carrying out polylocal osteotomy. Fragments selected on bone diaphysis segment are fixed within the boundaries of their anteroexterior part. Controlled distraction is applied for restoring the initial length of the segment. Stabilization is carried out by means of compression-distraction apparatus. The fragments selected on bone diaphysis are released from fixation at the bone regenerate restructuring stage. The diaphyseal fragments are released from fixation at the same time in particular cases. The diaphyseal fragments are released from fixation in known sequence beginning from proximal fragment in some other particular cases. EFFECT: prevented contractures development; reduced risk of traumatic complications. 3 cl, 4 dwg

Description

 The invention relates to medicine, in particular to orthopedics, and can be used in the treatment of patients with hip shortening of various etiologies.

 A known method of lengthening the femur by osteotomy and dosed longitudinal distraction of bone fragments to restore the required segment length with the subsequent stage of stable fixation using a compression-distraction apparatus (1).

 However, when the bone is elongated by a significant amount, the formed bone regenerate has significant dimensions, due to this it is subject to deformation and requires an extended period of stable fixation, necessary for its transformation into mature bone tissue.

 A known method of lengthening the femur, involving transosseous holding of locking needles, performing a multilocal osteotomy and dosed distraction of the selected fragments to restore the required segment length, followed by stable fixation using a compression-distraction apparatus (2).

 When performing this method, the spokes fixing the selected fragments of the diaphysis of the thigh are carried out in the direction from the front-inside, back-outside and front-outside back-inside, that is, they pass through the back muscle group. In the process of distraction, this causes a limited excursion of these muscles, a decrease in the function of the joints (knee), and pain. At the same time, taking into account the length of the period of stable fixation, this leads to the development of contractures, which increases the overall duration of medical rehabilitation of patients.

 The objective of the invention is to develop a method of lengthening the thigh, which reduces postoperative complications and the duration of medical rehabilitation of patients.

 This problem is solved in that in a method including transosseous holding of knitting needles, performing a multilocal osteotomy, dosed distraction of the selected fragments until the necessary segment length is restored, followed by their stabilization with the use of a compression-distraction apparatus until the regenerated regions are converted into mature bone tissue, the fragments bones selected during the diaphysis are fixed within their anterior-outer part, and at the stage of reconstruction of the bone regenerate they are released from fixation.

New in the proposed method is that the fragments isolated during the diaphysis of the bone are fixed within their front-outer part, and at the stage of reconstruction of the bone regenerate they are released from fixation. It is provided that
- diaphyseal fragments are released from fixation simultaneously;
- diaphyseal fragments are released from fixation sequentially, starting with the proximal located.

 The above allows you to judge the compliance of the proposed method with the criterion of "novelty."

 Analysis of available sources of information on the problem of limb bones lengthening shows that the proposed technical solution is not obvious and does not follow from the level of knowledge achieved in this area. This makes it possible to judge its compliance with the criterion of "inventive step".

 The applicability of the method is confirmed by the fact of its successful clinical use in the RTC "WTO" named after academician G.A. Ilizarova in the treatment of patients with shortened femur.

 The method is as follows.

 After anesthesia and treatment of the surgical field, femoral osteosynthesis is performed by known techniques. The entrance of its execution transosseously, cross-fixing needles are carried through the metaphysical sections of the bone. The peculiarity of conducting the spokes through the proximal metaphysis is that they are carried out in the oblique plane from the front-inside to the back-outside and from the front-outside to the back-inside. To increase the rigidity of fixation, use needles with thrust pads that are located on opposite sides of the bone. These spokes are attached to an arc support. The distal support is set in the projection of the distal metaphysis of the thigh. In the same plane, through the distal metaphysis in the direction from the front-outside to the back-inside and the back-outside to anterior-inside, conduct spokes that fix this part of the bone.

 Knitting needles designed to fix the femoral diaphysis fragments planned for isolation are transversely carried out perpendicular to the longitudinal axis of the bone in the direction from the front, from the inside, from the back to the outside, within its front-outer part. Moreover, they can be held both in parallel and the crosshair at an angle of 5 degrees with respect to each other. To increase the rigidity of fixation, along with these knitting needles, at each of the levels of their holding, an additional fixing element can be cantileverly introduced into the bone, also from the side of its outer-anterior surface, to a depth of the opposite cortical layer: a spoke or a rod. Such holding of knitting needles, which excludes “flashing” of the posterior muscle group, prevents the development of pain during distraction, allows early activation of the patient, and promotes functional recovery of the operated limb.

 In the tensioned state, the spokes are mounted on supports installed at the appropriate level, which are interconnected by threaded rods and hinged nodes with the possibility of dosed multi-plane movement.

 Through an incision in the skin and soft tissues, access to the surface of the femur and osteotomy is performed. Depending on the magnitude of the shortening, the osteotomy is performed multilocally at two, three or more levels in areas located between the spokes drawn through the diaphysis of the bone. At the final stage of the operation, wounds are sutured, control x-rays are performed, the apparatus systems are stabilized and aseptic dressings are applied.

 In the postoperative period, starting from 5-7 days, a metered longitudinal traction of the selected femoral fragments is carried out until the necessary segment length is restored. The traction rate for each of the selected fragments varies between 0.5-1.0 mm per day. Upon reaching the desired bone length and correcting, if necessary, its biomechanical axis, the apparatus is transferred to a stable fixation mode, which is maintained until the sections of the regenerate fragments formed as a result of dosed traction are reconstructed into mature bone tissue.

 At this stage, on the 8th day after the termination of traction — by this time the “growth zone” of the bone regenerate is closing — fragments of the femoral diaphysis free from fixation by removing the spokes drawn through them. The state of the proximal and distal articular (metaphysical) fragments with the spokes drawn through them is left unchanged. As a result of this, taking into account the tension of the muscle case, the position of the intermediate fragments of the diaphysis remains stable. At the same time, the removal of the spokes fixing these fragments contributes to a more rapid functional recovery of the muscle apparatus and prevents the development of joint contracture. In the presence of two or more isolated diaphysis fragments, their release from fixation can be performed both simultaneously and sequentially, starting with the proximal diaphyseal fragment, which is due to the faster course of organotypic restructuring of the regenerate in the proximal bone.

 Upon receipt of a reliable picture of complete bone consolidation, the apparatus is dismantled. The patient is prescribed a course of exercise therapy to work out a new stereotype of gait.

 The actual implementation of the method is illustrated by the following clinical observation.

 Patient O., 15 years old, was admitted to the clinic of the RTC "WTO" with a diagnosis of achondroplasia, low growth - 135 cm (figure 1). According to the proposed method produced a sequential lengthening of both thigh bones. During osteosynthesis, the fixing knitting needles were inserted through the proximal and distal metaphyses of the femur, as well as through the middle third of the diaphysis. In this case, the spokes fixing the diaphysis were carried out through the front-outer part of the bone perpendicular to its longitudinal axis with a small cross - up to 10 degrees relative to each other. At the same time, a cantilever spoke was inserted into it at the same level perpendicular to the axis of the bone to a depth of the opposite posterior-inward cortical layer. In a tense state, transversely held knitting needles were fixed on the apparatus supports installed at the appropriate level, which were connected to each other by threaded rods and hinged nodes with the possibility of metered movement. Through minimal skin incisions (up to 0.5 cm), a thigh corticotomy was performed at two levels: in its proximal and distal third, thereby forming an intermediate fragment of the diaphysis.

 The operation was completed by wound closure, aseptic dressings and stabilization of the apparatus.

 In the postoperative period, starting from the 5th day, dosed traction of the selected fragments was performed, the traction rate was 0.5 mm per day, and its duration was 48 days. As a result, the thigh was elongated by 9 cm (Fig. 2).

During the postoperative period, starting from the second day, the patient walked with a gradually increasing load on the limb. There were no complaints of pain (Fig. 3)
At the stage of stable fixation, 7 days after the cessation of distraction, the spokes fixing the central diaphyseal fragment were removed. The duration of the fixation phase was 56 days. After the complete dismantling of the apparatus, the patient underwent a course of exercise therapy.

 At the end of treatment, the axis of the operated limb is correct, the movement in the joints in full, the patient walks with a full load on the limb (Fig. 4).

 In a similar way, the second thigh was lengthened.

 The implementation of the method provides a reduction in postoperative complications and the duration of medical rehabilitation of patients.

Sources of information
1. Surgical lengthening of the thigh by G.A. Ilizarova / Methodical recommendations. - Kurgan, 1994 .-- 21 p.

 2. Elongation of the thigh according to Ilizarov after compactomy at two levels in patients with achondroplasia / Methodological recommendations. - Kurgan, 1992 .-- 21 p.

Claims (3)

 1. A method of hip lengthening, including transosseous holding of knitting needles, performing a multilocal osteotomy, dosed distraction of the selected fragments to restore the required segment length, stabilization with the use of a compression-distraction apparatus, characterized in that the fragments isolated during bone diaphysis are fixed within them front-outer part, and at the stage of reconstruction of the bone regenerate is released from fixation.  2. The method according to p. 1, characterized in that the diaphyseal fragments are released from fixation simultaneously.  3. The method according to p. 1, characterized in that the diaphyseal fragments are released from fixation sequentially, starting with the proximal located.

Images