RU2181267C2 - Method for treating delayed knitting consolidation and false articulations of long bones - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves fixing extremity segment in perosseous apparatus. Skin incision is done outside of the pathologic zone projection. Periosteum is detached upper and below of the false articulation or unconsolidated zone over a segment being not more than 3 cm long. Then, longitudinal incision is carried out over the whole pathologic zone in two planes running in perpendicular to each other. Compression osteosynthesis is carried out. EFFECT: accelerated treatment process. 4 dwg

Description

 The present invention relates to medicine, namely to traumatology and orthopedics, and can be used to accelerate the regeneration of long-growing fractures and false joints of long tubular bones.

 There is a method of treating long-growing fractures and false joints of long bones, the essence of which is that they use methods of compression osteosynthesis. At the same time, for example, at the level of the proximal metaepiphysis, an osteotomy of both tibia bones is performed and at the same time distraction of the leg bones in the proximal part is performed. After that, the fragments are compared, compressed and fixed in the Ilizarov apparatus until a full bone fusion is obtained [1].

 Closest to the proposed is a method of treating false joints and long-growing fractures of long bones using compression osteosynthesis in an external fixation apparatus. Various types of compression osteosynthesis provide maximum contact and complete permanent immobility between bone fragments. When applying an external fixation apparatus, the rings should be the same size, and the spokes should not be inserted close to the site of the pseudoarthrosis and adjacent joints. Subsequently, bone fragments are compressed. When obstructing the creation of compression of the fibula perform its osteotomy. With open interventions in the area of the false joint, an economical resection of the ends of the fragments (segmental resection, marginal resection, the formation of "locks") is performed with the opening of the bone marrow channels, necessary for better contact of the compared fragments [2].

However, the known methods have significant disadvantages, namely:
1. The creation of compressive forces at the junction of the fragments by the method of closed transosseous osteosynthesis does not always lead to fusion (up to 25 percent of cases), which can be explained by the insufficient value of the compression force and the temporary duration of the pathological condition. Compression at the junction of the fragments is not able to cause the rearrangement of the cartilaginous scar tissue through aseptic necrosis.

 2. Known technologies using various bone grafts lead to an increase in the duration and complexity of treatment due to the long reconstruction of the graft, lengthening the fixation period with an increased risk of soft tissue inflammation around the spokes.

 3. When using open surgical interventions to adapt bone fragments, the risk of infectious complications, the invasiveness of the intervention, violation of the trophic segment, as well as operational blood loss, increases.

 Based on the existing level of technologies for treating long-growing fractures and false joints of long bones, as well as eliminating the shortcomings of known technologies, the task was set: to ensure the fusion of bone fragments in a shorter time due to the creation of an intense focus of bone formation in the area of an overgrown fracture.

 The problem is solved using the following methods: treatment of long-growing fractures and false joints of long bones is carried out by osteotomy of a segment of a damaged limb and the use of compression osteosynthesis in an external fixation apparatus. New in solving the problem is that after fixation of a limb segment with a transosseous device, a skin incision is performed outside the projection of the pathological zone and the periosteum is detached above and below the zone of the false joint or nonunion no more than 3 cm long. Then, a longitudinal section of the bone is made through the pathological zone and both fragments bones in two mutually perpendicular planes.

 Explain the salient features of the proposed method.

 Performing a minimum skin incision (only along the width of the used chisel) outside the projection of the pathological zone allows you to save trophic surrounding tissues, reduce the risk of infectious complications.

 Detachment of the periosteum above and below the zone of the false joint or nonunion no more than 3 cm long enhances vascularization, causes the formation of new perioste-medullary vascular connections, improves trophism of the limb segment as a whole.

 Performing longitudinal dissection of the bone through the pathological zone and both bone fragments in two mutually perpendicular planes after detachment of the periosteum, allows creating four vascularized non-free transplants on each fragment, which leads to an increase in regional blood flow up to 3.6 times [3].

 The patent studies on subclasses A 61 B 17/56, as well as the analysis of scientific and medical information reflecting the current level of technology for the treatment of long-growing fractures and false joints of long bones, did not reveal identical methods. Thus, the proposed method of treatment is new.

 The interconnection and interaction of the essential methods of the proposed method ensure the achievement of a new medical result in solving the problem, namely, the provision of fusion of bone fragments in a shorter time due to the creation of an intense focus of bone formation in the area of non-fused fracture.

 The proposed method for the treatment of long-growing fractures and false joints of long bones can be widely used in clinical practice, since it does not require exceptional funds for use.

The essence of the proposed method for the treatment of long-fused fractures and false joints of long bones is as follows:
A patient who has a long-growing fracture or a false joint of long bones is placed on an injured segment with an external fixation device using known technology with possible correction of deformation and compression is created at the junction of bone fragments. From the skin incision outside the projection of the pathological zone, the periosteum is detached above and below the pseudoarthrosis or nonunion for no more than 3 cm on each fragment. Then, from the same minimum incision, a longitudinal osteotomy is performed through the zone of the pseudoarthrosis and both fragments are in two mutually perpendicular planes for at least 3 cm. In the postoperative period, compression is performed until the radiologically manifested inter-fragment diastasis disappears. Then begin the period of fixation until the fusion of bones.

The essence of the proposed method is illustrated by a clinical example:
Patient S., born in 1966, a driver by profession. In March 1994, he received an industrial injury: a closed comminuted fracture of the middle third of the right lower leg.

 In the duty city hospital, skeletal traction was applied for a period of 24 days. Then, bone osteosynthesis with an AO plate was performed; the wound healed by primary intention. After 2 weeks, the stitches were removed, a plaster cast for 2.5 months was applied. The fracture did not grow together. In November 1994 (7 months after the operation) a pseudoarthrosis was formed in the middle third of the leg, shortening the limb 1 cm. Deformation of the leg increased to 25 degrees.

 A year after the injury, the patient turned to the clinic ITO NTSRiVH VSNTS SB RAMS. Diagnosis at admission: Inadequate osseous osteosynthesis. The defect is pseudoarthrosis of the right tibia at the border of the middle and lower third with a shortening of 1 cm and varus deformity of the lower leg of 25 degrees. Contracture of the right ankle joint. Neuritis of the peroneal nerve.

On the roentgenogram of the right tibia at the border of the middle and lower third there is a slit-like inter-fragment diastasis. At the ends of the fragments, club-shaped bulges up to 1 cm. The tibia axis has a varus deformation of 25 degrees. Tibial fragments are fixed with a 8.5 cm long plate with three screws in each fragment (see the appendix to the description of figure 1)
Swelling of the lower leg + 3 cm, movements in the knee joint in full, in the ankle - 10/0/0. Tight pathological mobility in the pseudoarthrosis zone is 5 degrees. Walks with crutches, the load on the limb is up to 50 percent. With an increase in load - pain.

 03/21/96. the operation was performed - combined transosseous osteosynthesis of the right tibia. The AO plate was removed from the 10 cm incision. Mobility in the pseudoarthrosis zone increased to 15 degrees. To ensure unimpeded rapprochement of fragments of the tibia, an osteotomy of the fibula was made at the border of the middle and lower third. Deformation of the lower leg resolved simultaneously. To stimulate regeneration, a longitudinal osteotomy of the ends of the tibial fragments was performed over 2.5 cm in two mutually perpendicular planes. In the postoperative period, a compression of the pseudoarthrosis zone was created in the external fixation apparatus at a rate of 1 mm per day fractionally for 11 days. On the control x-ray - the state of the fragments is correct (see the appendix to the description of figure 2, figure 3 - function of the limb on the 4th day after surgery). The load on the limb is complete, a month after the operation I walked without supporting aids. On 71 days of fixation, a clinical test was performed - fusion was noted. It was planned to remove the device. For family reasons (father's death), the fixation period at the request of the patient was continued up to 99 days, after which the device was dismantled. Immobilization with a gypsum tire was not performed. Pseudoarthrosis has fused. Shortening the lower leg 1 cm. Movement in the ankle joint 20/0/0. The result of treatment is good (see the appendix to the description of figure 4). He works in the specialty.

 Thus, the proposed "Method for the treatment of long fused fractures and false joints of long bones" in comparison with other known technologies provides for the healing of fractures in a shorter time due to the fact that they create foci of intensive bone formation in the area of an overgrown fracture by performing detachment of the periosteum at the end of each fragment performing longitudinal osteotomy in the fracture zone with the creation of vascularized grafts.

Sources of information
1. A.S. USSR N 1335268, 1987, BI N 33, A 61 V 17/56.

 2. Shumada I.V., Rybachuk O.I., Zhila Yu.S. Treatment of false joints and defects of the diaphysis of the tubular bones. // Kiev: Health, 1985. - P.47-55.

 3. Barabash Yu.A., Barabash A.P., Gordienko V.P. Regional blood circulation and metabolic processes in the bones during the replacement of lower leg defects. // Materials of reports of the first international scientific and practical conference of traumatologists orthopedists of Crimea. - Yalta. - 1996. - S.9-10.

Claims (1)

 A method of treating long-growing fractures and false joints of long bones by osteotomy of a damaged limb segment using compression osteosynthesis in an external fixation apparatus, characterized in that after fixation of a limb segment in the transosseous apparatus, a skin incision is made outside the projection of the pathological zone and the periosteum is detached above and below the zone false joint or nonunion no more than 3 cm long, then produce a longitudinal dissection of the bone through the pathological zone in two mutually perp endicular planes.

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