RU2265413C2 - Belinov's apparatus for closed compression osteosynthesis for thigh-bone neck - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.

SUBSTANCE: apparatus can be used for breaks of thigh-bone's neck. Apparatus has case with lockers, guiding member and stencil bar with orienting needles. Case is made in form of two parallel vertical posts with supports and peephole disposed at lower part and connected together by means of screw and rod for getting closer to each other. Stencil bar is disposed at top part of posts in parallel to rod. Guiding member is made in form of removable guiding bushing and yoke fastened to post by means of arm-piece for vertical motion and rotation at two mutually perpendicular planes. Yoke is made in form cylinder provided with through hole for guiding bushing at top part and jack at lower part for connecting with arm-piece for rotation about its own axis. Guiding bushing is made in form of cylinder with central and peripheral channels for introducing needles for osteosynthesis. Peripheral channels are disposed along circle at angle to axis. Lockers are made in form of concaved plates to have holes for fixing needles and are mounted onto posts for vertical movement.

EFFECT: simplified operation access; better compression between fractures.

5 dwg, 2 ex, 1 tbl

Description

The invention relates to medicine, in particular to traumatology and orthopedics, and can be used to treat fractures of the femoral neck.

The frequency of femoral neck fractures according to I.V.Shumad, I.T. Knysh [1] is 5% of all tubular bone fractures. According to A.A. Fedyur and V.P. Grek [2], femoral neck fractures account for 8% of bone fractures of the musculoskeletal system.

Methods for osteosynthesis of the femoral neck are based on the use of various types of devices.

Known apparatus Demyanov for conducting guide the needle in the treatment of fractures of the femoral neck [3]. The device consists of two main parts, the base and the sector part, interconnected by hinges. The base of the apparatus has 2 holes for screws that secure the apparatus to the bones. Sector part consists of two graduated sectors. The horizontal (with the patient on the back) sector is located at right angles to the vertical and is still connected to it. The guide barrel of the apparatus is connected at one end with a hinge to the sector part. When the apparatus is in working position, its guide barrel can move in two mutually perpendicular planes - vertical and horizontal. The vertical trunk has a graduation from 0 ° (which corresponds to the horizontal plane with proper fixing of the device) to 20 ° up and down. The horizontal sector has a graduation from 0 ° (which corresponds to an angle of 130 ° relative to the axis of the femur) to 20 ° in both directions.

The disadvantage of this apparatus is that its fixation to the femur is impossible without an incision of the soft tissues in the undervert region. In addition, the use of the apparatus does not allow compression between fragments after reposition. The needle is introduced according to the anatomical landmarks, which does not always correspond to the required direction, so you have to make corrections after performing x-rays in 2 projections.

A known method of treating fractures of the proximal femur and a device for its implementation [4]. The device includes three rods and an arc with rod clamps. Due to the mobility of the clamps along and around the arc, the rods are inserted into the bone in different planes and at an angle to each other. Under the x-ray control, two rods are inserted through the puncture of the soft tissues into the undertrochanteric region, crossing the fracture lines, and the fragments are fixed. Clamps with holes are put on the rods, through which an arc is passed, orienting its concave part to the thigh. Using screws, the arc is fixed to the rods. Then, the third clamp is put on the arc, using it as a conductor, passed through the last third rod into the femur in front in the sagittal plane, the rod clamp is fixed with a screw and this ends the external fixation of the device.

Using the device does not allow to create compression between the fragments at the time of the rods through the fracture line, which does not exclude diastasis between the fragments. The device does not allow you to accurately orientate the direction of the rods, so they are carried out under the control of the image intensifier tube.

The closest technical solution to the claimed is a Kaplan guide apparatus for osteosynthesis of the femoral neck [5]. The apparatus is a 3 mm thick stainless steel plate with locks located on the inside along the edges of the plate. Parallel to the outer edge of the plate, a longitudinal groove with a movable pin is located on the side surface. Parallel to the groove, departing from it by 4 mm, 15 through landmarks were made.

A longitudinal incision 10-12 cm long is made on the outer surface of the subvertral region. A cortical layer of bone is drilled at the place where it is intended to guide the spoke. The device is strengthened on the outer surface of the femur with two nails driven into the bone through the fixators located at the edges of the plate. The movable pin of the guide apparatus is installed and fixed in the groove at the level of the proposed line of the femoral neck axis. Through one of the holes of the movable pin, a thick spoke is drawn into the neck and femoral head. X-ray diffractograms determine the position of the spokes and make adjustments. The needle is removed. Install the movable pin, taking into account the correction, and hold the spoke in the desired direction. Make a control x-ray. The device is removed. Then a three-lobed nail is held along the spoke. The needle is removed and a control x-ray is taken again. The wound is sutured in layers.

The disadvantage of this apparatus is that for its fixation, an incision of the soft tissues in the subtrochanteric region is required, which contributes to the risk of complications. The device does not allow the creation of compression between fragments at the time of the spoke. Driving a three-lobed nail is accompanied by additional trauma to the bone tissue, which is often accompanied by a complication - aseptic necrosis of the femoral head.

To simplify surgical access, create compression between the fragments being compared at the time of the spokes and to improve their fixation, the femoral neck is osteosynthesis using an apparatus consisting of two parallel vertical posts made in the form of hollow tubes with T-shaped supports and viewing windows in the lower parts connected at the top by horizontally arranged screw and rod with the possibility of rapprochement and removal relative to each other. At the racks at the level of the viewing windows, the bracket with the guide sleeve and the clips are movably fixed with brackets. In the upper part of the racks, a screen bar with knitting needles is motionlessly located.

The cage is made in the form of a cylinder with a through transverse hole for the guide sleeve in the upper part, a socket for connecting to the bracket with the possibility of rotation around its axis in the lower part, and holes for the fixing screws from above and from the side.

The guide sleeve is made in the form of a cylinder, which has central and peripheral channels located around a circle at a certain angle to the axis of the cylinder.

The latches are made in the form of concave rounded plates with holes for the locking spokes and are fixedly connected to the brackets.

The screen strip is made in the form of a narrow plate, which has a series of holes for the fixing bolts at one end and a thread for attaching to the rack from the other.

The design of the apparatus is illustrated by drawings.

Figure 1 is a direct projection.

1 - a vertical stand, 2 - a screw, 3 - a rod, 4 - a T-shaped support, 5 - a clamp, 6 - an arm, 7 - a holder with a guiding sleeve, 8 - a screen plate with knitting needles.

Figure 2 is a side view.

1 - a vertical rack, 4 - a T-shaped support, 6 - a bracket, 7 - a holder with a guide sleeve, 11 - holes for the spokes in the latch, 12 - an observation window in the rack.

Figure 3 is a top view:

1 - vertical stand, 2 - screw, 4 - T-shaped support, 8 - screen bar, 10 - guide sleeve.

Figure 4 - screen strip:

8 - screen bar, 13 - spoke, 14 - bolt-lock, 15 - nut.

Figure 5 - clip with a guide sleeve:

7 - clip, 10 - guide sleeve, 16 - central channel, 17 - peripheral channels, 18 - fixing screws, 19 - socket.

The device operates as follows.

The patient is repositioned of fragments on the orthopedic table with the abduction of the leg in the hip joint to an angle of 127-130 ° and internal rotation of 45 °, which displays the neck in a horizontal position. The limb is placed strictly parallel to the operating table (the vertical angle of the neck is 0 or 180 °). The degree of traction is determined by measuring the relative length of the thigh on a healthy and damaged limb. On the skin, in places corresponding to the centers of large skewers, dotted with brilliant green. The device is installed on top of the patient on the operating table so that the racks 1 were located in the area of large trochanters, and the marked points were visible in the viewing windows 12. A clip 7 with a guide sleeve 10 and a screen bar 8 are installed on the side of the damaged limb. The latches 5 are installed opposite the large trochanters and by rotation of the screw 2 of the rack 1 are brought closer to each other. At the same time, the retainers 5 fit snugly to the large trochanteric femurs, creating a compression between the fragments. The retainers 5 are additionally strengthened with knitting needles through the holes 11 to the bone. Do x-ray in 2 projections. The radiographs specify the comparison of fragments, the degree of compression between them, and determine the sector of passage of the spokes through the central channel 16 of the guide sleeve 10 in the projection of the screen strip 8 (horizontal angle of direction of the central channel of the guide sleeve). The clip 7 with the guide sleeve 10 is installed at a distance of 1-1.5 cm from the skin of the undervert region distal to the latch 5 and in one line (the horizontal angle is set according to the x-ray and the needles in the screen strip, the vertical is 0). Through the central channel 16 of the guide sleeve 10, a needle is passed into the neck and femoral head beyond the fracture line by 1.5-2 cm, an x-ray is made. As a rule, the central spoke passes through the center of the neck and femoral head. Clarify the depth of introduction of the spokes. Next, measure the length of the outer part of the Central knitting needles and subtract it from the length of the entire knitting needles to determine the depth of introduction of peripheral knitting needles. The spokes are introduced through the peripheral channels 17 of the guide sleeve to the calculated depth. The spokes form a cone, the top of which is located outside the guide sleeve, and the base of the cone is in the femoral head. The diameter of the base when holding the spokes into the neck and femoral head at a distance of 13 cm from the outer edge of the sleeve will be 3-3.5 cm, because the angle of direction of the peripheral spokes is 3.8-4.2 °

The device is dismantled. Outside the operating room, at the point of convergence of the spokes at a distance of 1.5-2 cm from the skin, i.e. the vertex of the cone is fixed with a plaster bandage (in the form of a ball), the bites behind it. This creates additional rigidity to the cone and closes the sharp ends of the spokes.

The use of this apparatus for osteosynthesis of the femoral neck allows the compression between fragments to be made without cutting the skin and fix them in this position with a bundle of needles, forming a bursting wedge in the form of a cone, with support points on the cortical layer at the junction of the femoral head into the neck and cortical layer subatroxial region, which creates stable osteosynthesis.

Example. Patient V., 72 years old, medical history number 4649 was injured when falling from the stairs. Hospitalized in the city hospital number 1.

Diagnosis: closed transcervical fracture of the neck of the left femur with displacement of fragments.

On the 2nd day after the injury, the operation was performed: closed reposition, compression osteosynthesis with a beam of diverging spokes.

During surgery, a compression apparatus was used. The operation was performed under spinal anesthesia. Reposition on the orthopedic table with the abduction of the left lower limb at 127-130 ° and internal rotation at 45 °. By measuring the relative lengths of the healthy and damaged hips, the degree of elongation was monitored. The central part of the large skewers was marked with diamond greens. Focusing on the labels, through the viewing windows in the racks 12, installed the device opposite the large skewers. Rotating the screw 2, brought the racks 1 together until the latches were in close contact with the spit area on both sides. The latches 5 were additionally reinforced with 2 knitting needles on each side through the holes 11. The holder with the guide sleeve and the screen bar were mounted on the left strut. Radiographs were made in two projections. The radiographs determined the comparison of fragments, the degree of compression, and the sector in which the central part of the neck and femoral head is located (sector 3 is located between 3 and 4 knitting needles in the stencil strip). Focusing on the knitting needles in the stencil strip 8, they held the spoke through the central channel of the guide sleeve into the neck and femoral head. An x-ray was taken in direct projection, the spoke passes through the center of the neck and femoral head and extends 1.5 cm beyond the fracture line. We calculated the distance by which peripheral spokes must be inserted. From the edge of the guide sleeve, it was 13 cm. Through the peripheral channels 17, 6 spokes 13 cm were inserted. The device was dismantled. Outside the operating room, at the point of convergence of the spokes, a gypsum bandage was wound, after which the spokes were tapered.

On the 2nd day after the operation, the patient is allowed to sit down, on the 3rd day to get up and walk on crutches without resting on the affected limb. On the 5th day the patient was discharged for outpatient treatment.

After 4 months on radiographs, the fracture was consolidated, the spokes were removed on an outpatient basis. Examined after 5 months. Movement in the hip joint in full. Walks with a reed on a cane.

Example. Patient V., 71 year old, story number 6268. She was injured when falling on the asphalt. Hospitalized in the city hospital number 1.

Diagnosis: closed subcapital fracture of the neck of the left femur with displacement of fragments.

On the 2nd day after the injury, an operation was performed, a closed reposition of fragments, compression osteosynthesis with a beam of diverging spokes.

During surgery, a compression device was used. On the x-ray taken during the operation, the central part of the femoral neck corresponded to sector - 4, through which the spokes were held at a distance of 13 cm from the edge of the sleeve.

On the 2nd day after surgery, the patient is allowed to sit down. For 3-4 days, get up and walk with crutches without resting on a sore limb. On the 5th day the patient was discharged for outpatient treatment.

Four months later, an X-ray control showed that the fracture was consolidating, the spokes were removed on an outpatient basis. The range of motion in the hip joint is normal. Full load on the limb is allowed after 5 months.

The effectiveness of the claimed apparatus and method is that after reposition, the fragments are pressed tightly against each other and the spokes are inserted through the guide sleeve at the time of compression. It creates high stability of osteosynthesis with low morbidity. The spokes are introduced around the circumference and at a certain angle in the form of a cone, the base of which is located in the femoral head. The top of the cone from the outside in the subtrochanteric region. Stable osteosynthesis allows a functional early load on the operated limb, which also contributes to the improvement of microcirculation and the consolidation of bone fragments of the primary type. The absence of skin incisions eliminates blood loss and suppuration of soft tissues. All this leads to a reduction in treatment time and early rehabilitation of patients.

For the period 2002-2003, 11 patients were operated using this device. See table No. 1.

Table number 1 Thigh neck (hallux valgus fracture). Average bed day Immobilization terms in weeks Rehabilitation terms in weeks Disability periods in weeks Method of treatment removable Total term Not physical labor Physical work 3-blade nail 30 ± 1 crutches 24 24-28 28 32 The treatment according to patent No.2016545 7 ± 1 crutches 22 22-26 26 28 Spoke bundle osteosynthesis 6 ± 1 crutches twenty 20-24 24 26

Complications of compression osteosynthesis of the femoral neck with a beam of diverging spokes:

1. false joint in 1 patient, the operation was performed 11 days after the injury under local anesthesia.

2. phlegmon of the hip in 1 patient in the late period. The fracture was consolidated after 4 months. Knitting needles removed. At the place of removal of the needles for 6 days suppuration of soft tissues.

Literature

1. Shumada I.V. Closed injuries of the hip joint / I.V. Shumada, I.T. Knysh. - Kiev: Zdorovya, 1969 .-- 229 p.

2. Fedyura A.A. On the timing of osteosynthesis in a fracture of the femoral neck / A.A. Fedyura, V.P. Grek // Orthopedics, traumatology and prosthetics. - 1989 - No. 19 - C 28-30.

3. Tkachenko S.S. Osteosynthesis / S.S. Tkachenko. - Leningrad: Medicine. - 1987. - 271 p.

4. A method for the treatment of fractures of the proximal femur and a device for its implementation: Auth. Certificate 1540813 of the USSR: IPC A 61 B 17/56, 17/58 / N.A. Koryshkov (USSR). Stated April 16, 91; Publ. 07/30/94. Bull. Number 14.

5. Auth. St. USSR No. 76673.

Claims (1)

An apparatus for introducing knitting needles for osteosynthesis in the treatment of fractures of the femoral neck, including a housing with retainers, a guiding element, characterized in that it is equipped with a stencil strip with indicative knitting needles, the housing is made in the form of two parallel vertical struts with supports and viewing windows in the lower part, connected at the top by a screw and a rod with the possibility of rapprochement, the screen strip is located in the upper part of the racks parallel to the rod, the guide element is made in the form of a removable guide sleeve and holder, reinforced with a bracket to the rack with the possibility of vertical movement and rotation in two mutually perpendicular planes, the casing is made in the form of a cylinder with a through transverse hole for the guide sleeve in the upper part and a socket in the lower part for connection with the bracket with the possibility of rotation around its axis, and the guide sleeve is made in the form of a cylinder with central and peripheral channels for introducing spokes for osteosynthesis, and the peripheral channels are located around a circle at an angle to the axis, f ixators are made in the form of concave plates with holes for fixing knitting needles and are mounted on racks with the possibility of vertical movement.

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