RU2261675C2 - Method for perosseous osteosynthesis of shin bones - Google Patents

Abstract

FIELD: medicine, traumatology.

SUBSTANCE: one should apply four needles through metaphysical tibial departments being both above and under the level of fracture in frontal plane and mount the apparatus based upon four rings, orient jointings of semi-rings in frontal plane, fix rods-screws to intermediate rings, withdraw rods-screws into tibia under acute angle towards longitudinal axis of osseous fragments, dismount at first marginal supports and then - posterior semi-rings of reposition-fixation supports in post-operational period taking into consideration clinico-roentgenological dynamics of osseous wound healing. The present innovation enables to decrease the risk for fixation contracture and infectious complications, improve conditions for healing osseous fragments and increase patient's quality of life during the whole course of fixation.

EFFECT: higher efficiency.

12 dwg, 1 ex, 1 tbl

Description

The invention relates to medicine, namely to traumatology, and is intended for the treatment of diaphyseal fractures of the lower leg.

A known method of transosseous osteosynthesis of diaphyseal fractures of the lower leg according to the method of G.A. Ilizarov (Osteosynthesis of closed fractures of the lower leg with the Ilizarov apparatus. Method, recommendations / Comp .: G.A. Ilizarov, A.A.Devyatov, B.K. Konstantinov. - Kurgan , 1976.- 46 p.). In this case, an apparatus of four rings is used. In the extreme (base) supports, located at the level of the metaphysical divisions of the bone, a pair of mutually intersecting spokes at an angle of 60-90 ° is carried out. In reposition-fixation supports, which are located in close proximity to the level of the fracture, spend on the spoke with a thrust pad.

The specified method has several disadvantages. Carrying spokes in metaphysical sections at an angle of mutual intersection of 60-90 ° leads to suturing of soft tissues where their thickness and displacement during movements in the nearby joint are relatively greater than in other positions at this level of transosseous elements. This leads to soft tissue trauma and is dangerous for the development of transfixation contractures and infectious complications. The gradual removal of knitting needles for the “education” of the regenerate at the end of the fixation period does not imply the gradual removal of external supports due to the particular layout of the apparatus. Therefore, throughout the entire period of fixation, a cumbersome arrangement of four rings remains.

Closest to the proposed invention is a method of combined (spoke-rod) transosseous osteosynthesis of fractures of the tibia (RF Patent No. 2062611). According to this method, four knitting needles are carried out in the frontal plane: two base and two repositioning-fixing. To ensure the rigidity of osteosynthesis in the immediate vicinity of the base supports, an additional 2 screw rods are introduced.

In this case, the screw rods are inserted parietally and parallel to the external cortical plate of the tibia at an acute angle to the nearby joint and are fixed in the base supports.

The disadvantages of this method include the bulkiness of the design: the layout based on four rings must be maintained throughout the entire period of fixation. Preservation of all transosseous elements increases the risk of infectious complications, contractures.

According to both methods, the joints of the half rings are placed in a plane close to the sagittal. This limits the possibility of modular transformation (partial dismantling of supports) during the fixation period.

The aim of the invention is to reduce the risk of fixation contractures and infectious complications, improve conditions for fusion of bone fragments, improve the quality of life of the patient during the fixation period.

This goal is achieved by the fact that initially the apparatus is mounted on the basis of four external supports: two basic at the level of metaphysical departments and two intermediate (reposition and fixation). In this case, the joints of the half rings of the outer supports are oriented in the frontal plane. At the level of each support in the frontal or close to her plane spend one spoke. In addition to reposition and fixation knitting needles, intermediate rods are fastened with screw rods that are inserted into the bone according to the following procedure.

An injection needle is inserted into the soft tissue of the lower leg of the subperiosteal external cortical plate of the tibia, which later serves as a guide. The radiograph of the lower leg determines the thickness of the outer cortical layer of the tibia. The resulting distance is measured inwards from the established landmark. The resulting point is the place of introduction of the screw rod. Next, the screw-rod is installed at the required angle to the longitudinal axis of the bone fragment and is held in the bone parallel to the reference point - the injection needle. As a result, the rod-screw is installed in the tibia parietally and parallel to its outer cortical plate and at the same time at an acute angle to the longitudinal (long) axis of the bone fragment (Figs. 1 and 2).

In fractures, usually after 5-7 weeks from the moment of surgery, the patient can give a painless axial load within 50-70% of the body weight, walks with one crutch. Soft tissue edema is absent or does not exceed + 1-2 cm of the circumference of the segment at the fracture level. Movement in the knee joint is limited only by focusing on the proximal base support (if it is not 3/4 of the ring); in the ankle within 40/0/10. Radiologically during this period, a gentle periosteal regenerate is higher than the density of soft tissues on all surfaces of the adjacent ends of the fragments; there is a pronounced endosteal regenerate in the form of fuzzy contours of adjacent ends of fragments with signs of rarification (erosion of the cortical layer) of cortical plates of the ends of fragments. These clinical and radiological signs are the basis for the dismantling of the base supports of the apparatus. Thus, in the subsequent period of fixation, the layout of the apparatus includes only two ring supports.

After 8-10 weeks from the moment of surgery, the load on the limb increases to 70-100%, the patient can move with or without a cane; movements in the knee and ankle joints are not limited; a clinical fusion test shows the presence of tight depreciation. By this time, compaction of the periosteal regenerate of the connecting fragments over all surfaces with differentiation of its bone structure is determined by x-ray; single longitudinally oriented shadows of the newly formed bone regenerate are traced in the inter-fragmental fissure, there are initial signs of the formation of a single cortical plate, as well as initial signs of the construction of the bone marrow cavity. These clinical and radiological signs are the basis for dismantling the rear half rings of the remaining external supports. Thus, by the end of the fixation period, the arrangement of the apparatus includes only two spokes and two screw rods fixed in two half rings.

The initial arrangement of the apparatus on the basis of four rings creates optimal conditions for the reposition and fixation of bone fragments: first, carry out the basic knitting needles, mount the apparatus, give distraction between the fragments, and with the help of reposition and fixation spokes achieve accurate reposition. Holding spokes in the frontal plane provides the prevention of contractures and infectious complications. The introduction of screw rods provides the rigidity of fixation of bone fragments necessary for early functional treatment. Fixing the screw rods to the intermediate supports determines the ability to subsequently remove the outer rings of the apparatus.

The orientation of the joints of the external supports in the frontal plane makes it easy to remove the rear half rings. In this case, the spokes fixed in the front half rings completely retain their repositional-fixative value.

As you know, an increase in the load on bone regenerate in accordance with the growth of its bearing capacity has a positive effect on its functional restructuring. Gradual dismantling of supports and removal of transosseous elements leads to the dynamization of the apparatus.

To substantiate the proposed method for transosseous osteosynthesis of lower leg bones, biomechanical studies were carried out. The results are presented in table 1, where:

- "design No. 1" - apparatus G.A. Ilizarov (Figure 3);

- "design No. 2" - the apparatus according to the patent of the Russian Federation No. 2062611 (Figure 4);

- "design No. 3" - the apparatus according to the proposed method with the introduction of srednee-screws at an acute angle to the longitudinal axis of the bone fragments (Figure 5);

- "design No. 4" - an apparatus based on two rings (Fig.6);

- "design No. 5" - an apparatus based on two half rings (Fig.7);

An analysis of the data obtained suggests that the newly proposed transosseous apparatus arrangement provides an osteosynthesis stiffness greater under axial loading than G.A. Ilizarov osteosynthesis and equal in comparison with the apparatus according to RF patent No. 2062611.

Dismantling of the extreme supports, and then the rear half rings somewhat reduces the rigidity of osteosynthesis, leads to the dynamization of the apparatus, which has a positive effect on the functional reconstruction of the regenerate. In addition, the removal of spokes held near the knee and ankle joints is the prevention of contractures and infectious complications. A gradual decrease in the bulkiness of the apparatus (from four rings to two half rings) significantly increases the quality of life of the patient, facilitates maintenance of the structure.

Based on this method, osteosynthesis can be performed not only with fractures, but also with the consequences of shin bone fractures (fragment fusion in the wrong position, delayed fragment fusion, false joints, deformations).

Demonstrate what was said by clinical observation.

Patient S., 48 years old, medical history No. 5234. November 17, 2002 there was a closed fracture of the bones of the left tibia on the border of the lower and middle third of its diaphysis with displacement of fragments, closed fracture of the posterior tibia (Fig. 8.1). November 21, 2002 a combined transosseous osteosynthesis was performed using an apparatus based on four supports (Fig. 8.2). 47 days after the operation, the patient could move with a cane. During this period, a gentle periosteal regenerate was higher than the density of soft tissues radiographically on all surfaces of the adjacent ends of the fragments; there was a pronounced endosteal regenerate in the form of fuzzy contours of adjacent ends of fragments with signs of cortical plate rarification of the ends of the fragments. 01/06/2003 the base supports of the apparatus were dismantled (Fig. 8.3). 02.11.2003 the rear half rings were dismantled (Fig. 8.4). 02/25/2003 (97 days from the moment of operation) the device was dismantled (Fig. 8.5). It took 2 weeks to fully restore limb function and the patient began to work in her specialty (pediatrician).

Method for transosseous osteosynthesis of lower leg bones

Table 1.
The stiffness indicators of various transosseous devices Axial load N / mm Rotational load H / degree Transverse load N / degree compression distraction sagittal plane frontal plane construction number 1 55 55 8 thirteen 12.5 construction number 2 110 105 nine 10 16 construction number 3 115 110 nine 14 16 construction number 4 75 75 7 4,5 4,5 construction number 5 73 73 5 4 4,5

Claims (1)

Method of transosseous osteosynthesis of lower leg bones with conducting through metaphysical sections of the tibia, above and below the fracture level of four spokes in the frontal plane, introducing two screw rods into the tibia, installing an apparatus based on four rings, characterized in that the joints of the half rings are oriented in the frontal plane , the screw rods are fixed to the intermediate rings and injected into the tibia at an acute angle to the longitudinal axis of the bone fragments, and in the postoperative period, based on clinical rent genetic dynamics of healing of a bone wound, first the extreme supports are dismantled, and then the rear half rings of reposition-fixation supports.

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