RU2229856C2 - Method for carrying out fragment osteosynthesis after intertrochanteric femur osteotomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves introducing sharp plate ends into proximal fragment as far as control openings become visible above the bone surface. Elongated leg of U-shaped guide reference member is introduced into one of the openings. Shortened leg is directed towards a lower opening hidden in spongious layer. A canal passing through the second opening is formed with the U-shaped guide. The guide is withdrawn. Spike nail is introduced via the built canal. The manipulations are repeated in the like order at the place the second plate end passes. Supporting screw is screwed in through lower slot in the plate. Screw head and the plate are caught with C-clamp through the upper slot. The grippers are made close to compressing femur fragments. The plate is fixed with screws via the openings produced in plate border through rigidity rib bases arranged along plate length. EFFECT: high accuracy in introducing spikes; simplified and reliable fastening. 11 dwg

Description

The present invention relates to medicine, namely to traumatology and orthopedics, and can be used for immersion fixation after corrective intertrochanteric osteotomy of the femur.

A high percentage of disability and disability of patients with dysplastic and deforming coxarthrosis determine the urgency of improving the known and the search for new methods of treating coxarthrosis. (I.V. Shumada et al., 1982; N.I. Kulish et al., 1992; V.M. Mashkov et al., 1993, etc. // cited by S.V.Sivov, Abstract of dissertation on Candidate of medical science degree: Corrective osteotomy of the proximal end of the femur in the treatment of patients with dysplastic coxarthrosis (Nizhny Novgorod, 2001).

The main methods of treating deforming coxarthrosis are surgical (Yu.I. Yezhov, 1989; V.M. Mashkov, 1993; N.V. Kornilov et al., 1997; V.P. Moskalev et al., 1998 // cit. S.V. Sivov, 2001).

All known operations are divided into two groups: reconstructive and reconstructive and endoprosthetics of the hip joint. At present, it is obvious that the long-term results of endoprosthetics turned out to be significantly worse than the nearest ones (I.P. Durmanova, 1995, cited by S.V.Sivov, 2001; A.F. Lazarev et al. Man and his health, 1998, p. 30-31; O.Sh. Buachidze et al. Man and his health, 1997, p.16; V.P. Okhotsky et al. New technologies in medicine. 4.1. Kurgan. 2000, p.229; Yu.I. Yezhov et al., Ibid., P. 84). In addition, endoprosthetics remain an inaccessible operation for the general population due to the high cost of products (A.L. Plyushchev et al. Endoprosthetics, arthroscopy, osteosynthesis. M., 2000, pp. 3-7).

One of the main trends in the development of methods for surgical treatment of dysplastic or deforming cocartrosis, including osteosynthesis of fragments of the femur, is the improvement of reconstructive surgery (S.S. Tkachenko et al., 1990; V.M. Mashkov, 1993; V.P. Voloshin , 1995; Yu.I. Ezhov, 2000 // cited by S.V.Sivov, 2001 /; N.I. Zhadenov et al. New Technologies in Medicine, 4.1. Kurgan. 2000, p. 89)

The most common interventions in the treatment of patients with coxarstrosis include corrective osteotomy of the proximal femur. The positive results of such operations are directly related to strong osteosynthesis during medial dislocation of the diaphyseal-femoral fragment after intertrochanteric osteotomy. Such osteosynthesis is possible only by submersible metal osteosynthesis.

A known method of osteosynthesis using a plate-slipper A.V. Kaplan and A.I. Antonova, which is used as a fixator after an osteotomy and displacement of the distal femur fragment under his head. Before attaching to the trochanter of the thigh, the plate is bent by hand in such a way that its teeth at the upper end cut into the spongy of the greater trochanter on the side and top. Then, the distal half of the plate is fixed to the diaphysis from the outside with 4-5 screws (screws) (A.V. Kaplan. Elderly traumatology. M., 1977, p. 252-253). The disadvantage of this method is the relative weakness of osteosynthesis. This requires additional coxitic plaster casts.

There is a method of osteosynthesis of femoral fragments using the Trotsenko-Nuzhdin plate (I. A. Movshovich. Operational orthopedics, 1994, p. 38 and 213). The plate is inserted into a large trochanter from below, fastened with screws to the diaphysis, and the movable part of the plate in the form of an arcuate curved hoes having a rotation axis and a movable-rotational connection with the monolithic part of the plate, and a pointed spike at the free end, are introduced from the outside into the large trochanter after medialization and using a removable screw device (clamp), as if stringing the pointed ends of the monolith create a compression effect between the trochanter and diaphysis of the thigh.

The main drawback of the Trotsenko-Nuzhdin design is that the arcuate cap plate limits the medialization of the diaphysis due to the small therapeutic range of movement of the diaphyseal fragment under the neck, closer to the femoral head.

Known plate V.M. Demyanova with a lever vise contractor (N.V. Kornilov et al. Surgical treatment of degenerative-dystrophic lesions of the hip joint. S.Pb., 1997, p. 89 and 91).

A well-known plate of Kharkov NIIITO for fixing bone fragments after intertrochanteric osteotomy. It is accepted by us as a prototype. The method is carried out: after intertrochanteric osteotomy and displacement of the diaphyseal fragment medially, two pointed ends of the plate with one hole on each of them are introduced from the bottom to the top of the trochanter, and these holes are not visible. Only with the help of a special removable guide, which is mounted on the proximal diaphyseal part of the plate, they are oriented to the skewer and through the spongy from outside to inside, an awl is directed so that its end first passes through the hole in one end of the plate immersed in the skewer. Then the awl-guide is removed and a special tetrahedral nail - “crutch” is introduced through the channel formed by it. The nail must pass through the hole so that the plate provides a secure fit. Similarly, they prepare and, without removing the guide, insert a “crutch” into the second hole, which ensures strong retention of the greater trochanter and the entire proximal fragment.

After a sufficient displacement of the diaphysis and small trochanter under the femoral neck, the free end of the plate is placed on the femur and tightly pressed to the diaphysis. In a special round hole located in the center of the plate, a compression washer is installed on which a square protrusion is eccentrically made with a through eccentrically located screw hole. Without loosening the retention of the plate on the thigh, an hole in the cortical layer is drilled with an electric drill and a screw is screwed through the hole in the eccentric. Then the key rotate the eccentric 180 degrees. In this case, compression between the fragments along the osteotomy line occurs. If the compression is not sufficient, then after the first compression, the eccentric is moved and again an attempt is made to increase compression.

The disadvantages of this method are:

1. The probability of the awl-guide slipping past the holes at the ends of the plate and, as a result, introducing a “crutch”, bypassing these holes, that is, without fixing a large skewer. As a rule, this is determined only radiologically, after surgery, and sometimes weeks later, at the outpatient stage of treatment.

2. The HarNIITO plate is made of sheet steel by stamping, which in some cases can cause its fractures at the stage of outpatient treatment and subsequent nonunion at the site of the hip osteotomy.

3. Compression by the eccentric may be insufficient, shifting the eccentric and re-compression of the femoral fragments may require considerable time and increase the duration and invasiveness of the operation.

Tasks:

1. To simplify the accuracy of the introduction of “crutches” in the holes of the ends of the plate perforating a large skewer.

2. Create conditions for the possible preservation and structural integrity of the neck and head during medialization of the thigh.

3. Technically, to make the removable compression device simpler and more reliable, and using it to create optimal therapeutically justified compression efforts of the trochanteric and femoral fragments after the intertrochanteric medializing hip osteotomy.

The essence of the method is that the ends of the plate are introduced into the proximal fragment and the appearance of control holes is visually determined, being guided by the channels passing through the holes hidden in the spit spine, and stabilizing nails-crutches are introduced into these channels, and a thrust screw is screwed into the diaphysis, the head of which is gripped with a clamp and fragments of the thigh are pressed with their subsequent fixing with screws through the holes along the edges of the plate stiffeners.

The plate is a flattened device (figure 1), which at the edges has longitudinal stiffeners along the entire length (item 1). The upper third of the plate is represented by two pointed ends (pos. 2), in each of which through holes (pos. 3) are made, located symmetrically at exactly the same distance from each other. A groove (pos. 4) is made between the pointed ends of the device, which, when switching to the diaphyseal part, has a narrowing (pos. 5), which makes the plate stronger in the part located on the line of the femur osteotomy and prevents its fractures during outpatient treatment, when the patient can conduct rehabilitation treatment. The diaphyseal part of the device is fixed to the femur, for example, with a bone holder, after which, at the groove level (pos. 6), closer to the lower edge of the plate, a cortical layer is drilled with an electric drill and a screw is screwed, the head of which should stand a few millimeters above the plate and subsequently should serve as a stop for gripping the compression clamp - figure 4. On the diaphyseal plate of the plate, through holes (pos. 8) are made at the edges for screws, which, after compressing the fragments, the device is fixed to the diaphysis. Moreover, the holes are made at different levels and in different directions at an angle to the frontal and sagittal planes of the thigh.

The method can be implemented using the devices shown in figures 1-10, as follows. After the intertrochanteric medializing osteotomy (Fig. 6), the ends of the plate (pos. 2) are introduced from below into a large trochanter until the holes above the bone (pos. 3) exit. Focusing on these holes in one of them enter the elongated leg (10) of the U-shaped guide (figure 2). At the same time, the shortened leg (pos. 11) is strictly oriented to the second hole located below in the spinal layer (Fig. 1 and Fig. 7). Having deepened the U-shaped guide, they fall into the second hole. The guide is removed and a nail-crutch is introduced along the channel formed by the foot (Fig. 7 - Pos. 11). In a similar sequence, these manipulations are repeated at the point of passage through the great trochanter of the second pointed end of the plate. If the need arises, then the same manipulations are carried out to introduce the third and fourth crutch nails. Thus, the proximal fragment carrying the head, neck and large trochanter is firmly held by the device.

The diaphyseal part of the plate is temporarily pressed and held on the tubular part of the femur. Then, at the level of the lower half of the plate, a hole is made in the slot (Fig. 1 - item 6) in the cortical wall of the diaphysis and the screw is screwed into it (item 9) (Fig. 8) so that its standing hat allows it to be gripped with the lower with a special protrusion of the clamp jaw (pos. 13) (Fig. 4 and Fig. 9), in which a cut is made under the screw head (Fig. 8). The upper jaw grip (key 12) (figure 4 and figure 9) holds and fixes the plate through the groove (key 5) (figure 1). Next, one of the ends of the pivot arm (Fig. 5) is inserted into one of the holes (key 15) of the clamp (Fig. 4 and Fig. 9) and, rotating the screw shaft (pos. 16), the grips (pos. 12 and 13) are brought together ), which provides compression of the trochanteric and diaphyseal fragments.

In the position of the given compression, the plate is fixed with screws. To do this, through the holes (pos. 8) (Fig. 1), a series of holes are made into the diaphysis with an electric drill and 2-4 screws (pos. 17) are screwed from two sides diametrically into the femur (pos. 17) (Fig. 10). Moreover, due to the fact that the holes for the screws on each side are made at different levels, the screws in the bone marrow canal do not intersect and create a stable fixation, which is proved by clinical and radiological observations. The final position of the plate on the hip is shown in Fig.11.

Using the claimed device, we performed 15 operations of corrective osteosynthesis of the proximal end of the femur in patients with deforming coxarthrosis, mainly women aged 17 to 66 years. All achieved fusion in the period from 16 to 20 weeks. In the distant postoperative period, the supporting functions of the limb are preserved or restored. There is no pain.

Thus, the main distinguishing features of the claimed device from the prototype are the following.

Prototype

1. Has only one hole at two ends embedded in the skewer.

2. Both ends are immersed in the inside of the spongyon spit.

3. The holes are immersed in the spongy spit and are not visible.

4. To determine hidden holes, a complex removable guide should be used, which does not guarantee that a nail-crutch gets into the holes of the ends of the plate.

5. For compression synthesis of bone fragments, a rounded washer with an eccentrically made square protrusion under the rotary key is introduced in the middle part of the plate. After screwing the screw through the eccentric into the diaphysis, the eccentric is turned 180 degrees with a key, limited compression is performed.

6. To fasten the plate to the diaphysis, the holes for the screws are made longitudinally along the midline, and the screws are screwed in one frontal plane.

The inventive device

1. Has several holes along two ends held in a skewer.

2. Both ends perforate a large skewer.

3. Both holes at the ends of the device stand above the bone and are visually determined.

4. A U-shaped reference guide is inserted with one leg into the visible holes and allows you to quickly and accurately identify the second or third holes at the ends of the device, hidden in the spongy part of the greater trochanter.

5. Compression is carried out with a clamp. For this, a screw is screwed through the lower groove of the device into the femur. The size of the groove does not limit the longitudinal movement of the diaphysis to the trochanter. The screw is the capture point of the femur, and the capture point of the device is a groove in the plate under the spit.

6. The holes for the screws for attaching the device to the diaphysis of the thigh are made on both sides through the base of the stiffeners, do not match in height, and the screws are screwed in different directions, at an angle to the frontal and sagittal plane

The medical and social effect of the present invention includes improving the quality of organ-preserving corrective osteotomy of the proximal femur in patients with degenerative-dystrophic coxarthrosis at subcompensated stages of the disease by simplifying the accuracy of introducing fixing crutches during fixation of the greater trochanter, creating conditions for maintaining or possibly improving the integrity of the neck and head with medialization of the thigh. Technically, the proposed device is sufficiently simple and reliable mounting in the optimal compression of fragments after intertrochanteric osteotomy of the thigh.

Claims (1)

Method for osteosynthesis of fragments after intertrochanteric osteotomy of the thigh, including fixing fragments using a plate, characterized in that the pointed ends of the plate are inserted into the proximal fragment until the control holes extend above the bone, an elongated leg of the U-shaped guide pattern is inserted into one of them, the shortened leg is oriented on a lower hole located hidden in the spongy layer, a channel passing through the second hole is formed with a U-shaped guide, a guide is removed along the formed channel they use a “crutch” nail, in the same sequence, repeat the manipulations at the place where the second end of the plate passes, screw the thrust screw through the lower groove of the plate into the diaphysis, grab the screw head with the clamp and the plate through the upper groove, tighten the grips, compressing the fragments of the thigh, fix the plate with screws through holes made along the edges of the plate through the base of the stiffeners located along the length of the plate.

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