RU2285502C2 - Method for restoring supporting ability of lower extremity after removing knee joint endoprosthesis with wound infection complication - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves excising distal femur segment and proximal tibia segment. Tibial osteotomy is carried out at two levels. Bone fragment is mobilized on vascular fascicle. Fibular graft is rotated per 180°, conducted under frontal crural muscle group and the graft ends are introduced into prepared femoral and tibial bone bed.

EFFECT: enhanced effectiveness of treatment; accelerated fractured bone consolidation.

4 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics.

Despite the continuous improvement of knee joint endoprostheses, good equipment with instruments, extensive clinical experience of domestic and foreign orthopedists, up to now 5-7% of operated patients have infectious complications in the early stages after surgery and in the long term (Install et al., 1983; Wilson et al., 1990). If it is not possible to maintain endorrheosis in conditions of wound infection, extensive defects of the bones that form the knee joint often occur. The impossibility of restoring the lower limb support ability by traditional methods is determined by a number of reasons: the presence of a chronic purulent focus, shortening of the limb, and the need for prolonged external immobilization. All of the above often determines the indications for amputation of a limb at the hip level or the constant wearing of an orthosis without the possibility of support.

Treatment aimed at the rehabilitation of this group of patients does not have unambiguous tactics according to available foreign and domestic orthopedics.

Analogues of our proposed technique include the method of internal and external fixation of bone fragments (intra-, extramedullary methods) proposed by V. D. Chaklin in 1932 using a non-blood-supplied auto- or allograft (Chaklin V.D., 1964; Movshovich I.A. ., 1994). It seems to us that the closest analogs also include the method of osteoplastic resection of the knee joint according to Boychev, when after the resection of one of the bones that form the knee joint, the resulting defect is filled with a bone necroscopic autograft from an adjacent healthy bone (Boychev B. et al., 1961).

However, these techniques have several disadvantages. First of all, the use of massive necroscopic auto- and especially allografts left in the deep layers of the wound increases the risk of recurrence of wound infection in the postoperative period. In addition, in anticipation of bone fusion and compensatory restructuring of the graft, able to withstand the load of body weight when walking, patients are forced to use protective removable tutors for many months, which delays the process of social and labor rehabilitation of patients.

When analyzing the literature available to us, the closest invention to the technique we have proposed is the Gan-Codiwill-Huntington operation, which consists in the staged movement of the blood supply to the fibula to the tibia defect (Movshovich I.A., 1994), as well as a method for plastic surgery of the distal femoral defect bones by transposition of the fibula on the vascular pedicle, proposed by A.E. Davis and V.G. Golubev in 2002.

Paying tribute to these methods, it should be noted that they are used only for isolated defects of the femur or tibia. These operations involve the use of fixing immersion elements, which is dangerous in the focus of infection due to the risk of exacerbation of the purulent process. Therefore, in our opinion, it is justified to use an external fixation apparatus that holds a fragment of the fibula for the time of consolidation of the latter.

The lack of microsurgical technology allows, with some experience, the use of this method in all surgical hospitals.

The technical result of this invention is to restore the limb length and its supportability by moving the blood supply fragment of the fibula, which allows to achieve arthrodesis of the knee joint zone with significant bone defects that occur after removal of the endoprosthesis and surgical treatment of the osteomyelitis focus of the thigh and lower leg, as well as to achieve rapid bone fusion and adaptive restructuring of the graft in the focus of chronic infection in conditions of reliable blood supply.

The indication for this operation is the presence of a defect in the proximal tibia and distal femur after operations performed for the removal of the knee joint prosthesis in conditions of wound infection, in the absence of trophic disorders of the integumentary tissues and intact fibula and its vessels on the affected side.

The method is as follows. After removal of the knee joint endoprosthesis, resection of the distal femur and proximal tibia within the unchanged bone tissue and wound repair under the tourniquet, the incision continues along the outer surface of the lower leg in the projection of the fibula to the required length. The fibula with surrounding soft tissues and vessels entering it is distinguished. An osteotomy is performed at the upper and lower levels, mobilization of a bone fragment on the vascular bundle. By removing the tourniquet, the state of blood supply to the fibular graft is assessed. The latter is rotated 180 degrees, carried out under the anterior group of leg muscles and placed in the area of the bone defect. The ends of the graft are inserted into the prepared bone bed of the femur and tibia. Taking into account the axis and limb length, an external fixation apparatus is installed with the main supports on the thigh and lower leg. Layer wound closure is performed with active drainage remaining. The external fixation apparatus was removed 3-4 months after surgery with the corresponding radiological signs of transplant fusion with the recipient bed. Before the final adaptive reconstruction of the tibia, patients used a removable orthosis.

Thus, the use of this method allows you to restore the length of the limb and its supportability.

Clinical example.

Patient S., 41 years old, and / b 2194/04, was hospitalized in the department of purulent surgery RosNIITO them. PP Harmful on 10.03.04 with a diagnosis of chronic postoperative osteomyelitis of the right thigh and lower leg, remission phase, condition after removal of the total endoprosthesis of the right knee joint, RCHO of the thigh and lower leg of March 2003. Defect - diastasis of the bones that form the knee joint 12 cm. She had a history of total endoprosthetics of the right knee joint in 1994 for fibrous ankylosis. In January 2003, due to the instability of the components of the endoprosthesis, endoprosthesis replacement was performed (Fig. 1). In the early postoperative period, suppuration of the wound, sepsis, which required the removal of an artificial joint (figure 2). Upon admission to the department, she moved without relying on a limb with crutches. Constant fixation of the limb in the orthosis was carried out. After clinical and radiological examination, the operation was performed to restore the support ability of the lower limb by replacing the bone defect with a blood-supply peroneal graft rotated 180 degrees, overlapping AVF (figure 3). Three months after the operation, according to the X-ray and clinical examination, the apparatus was dismantled, further limb fixation was carried out in a removable orthosis. Six months after the operation, it moves with a cane, axial load up to 30 kg is possible (Fig. 4).

Bibliography

1. Boychev B. Operative orthopedics and traumatology / B. Boychev, B. Conforti, K. Chokanov. - Sofia: Medicine and Physical Education, 1961. - 832 p.

2. Davis A.E. Transposition of the fibula on the feeding vascular pedicle for plastic surgery of defects in the distal femur / A.E.Devis, V.G. Golubev // Vesti. traumatol. and orthopedist, im. N.N. Priorova. - 2002. - No. 2. - S. 46-49.

3. Movshovich I.A. Operative orthopedics. - M .: Medicine, 1994 .-- 445 p.

4. Chaklin V.D. Fundamentals of operative orthopedics and traumatology. - M .: Medicine, 1964 .-- 737 p.

5. Insall J. Two stage reimplantation for the salvage of infected total knee arthroplasty / J. Insall, F. M. Thompson, B. D. Brause // J. Bone Jt. Surg. - 1983. - V.65-A, No. 6. - P.1087-1093.

6. Wilson M.G. Infection as a complication of total knee-replacement arthroplasty / M.G. Wilson, K. Kelley, T.S. Thornhill // J.Bone Jt. Surg. - 1990. - V.72-A, No. 6. - P.878-883.

Claims (1)

A method for restoring lower limb support ability after removal of a knee joint endoprosthesis under conditions of a wound infection, including resection of the distal femur and proximal tibia, characterized in that osteotomy of the fibula is performed at two levels, a bone fragment is mobilized on the vascular bundle, a graft is transplanted from the mouth 180 °, carried out under the anterior group of leg muscles, the ends of the graft are introduced into the prepared bone bed of the femoral and tibial Tei.

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