RU2290122C1 - Method for carrying out plastic repair of humerus head impression defects - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves using granulated porous titanium nickelide. Defect cavity is filled with mixture containing the implant and defect bone fragments after exposing and sequestering the bone fragments. The defect is covered with porous titanium nickelide plate and transosseously fixed with titanium nickelide clamp together with adjacent tendons.

EFFECT: full scale functional articulation repair.

6 dwg

Description

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

In some cases, a shoulder dislocation is accompanied by an impression (indented) fracture of the humeral head as a result of the articular depression of the scapula being pressed into it. In the presence of such a defect, especially the articulated surface of the head, the corrected dislocation can be repeated, since the impression defect has the form of a deep saddle depression, which disrupts the normal fixation of the head in the articular cavity. The limb loses its working capacity, the patient is disabled.

Surgical treatment methods (joint plastic surgery, arthrodesis) are reduced to restoring the normal in shape, biologically stable, mechanically strong head of the humerus (on the medical slang - the shoulder). The progress of this area of surgery depends significantly on the quality of the materials used to replace the defect and the associated methods of performing the operation.

A known method of plastics impression defects of the head of the humerus [A.F. Krasnov, RB Akhmedzyanov. Dislocations of the shoulder. M .: Medicine, 1982, S.93-94], based on the rise of the bottom of the pressed defect to the level of the articular surface. For this, after exposure of the head of the damaged humerus, two diametrically located holes are drilled in it at a distance of 1.5-2 cm from the boundary of the fracture in the direction of the bottom of the pressed defect. The narrow ends of the bone elevators are introduced into the openings and, acting as levers, they raise the pressed fragments from the bottom up to the full restoration of the normal convexity of the head in place of the impression defect. Top zone of the defect is covered with a fibrous membrane and sutured (figure 1). An educated void requires long periods of overgrowing with local tissue and rehabilitation of an immobilized limb.

A known method of plastics impression defects of the head of the humerus [A.F. Krasnov, RB Akhmedzyanov. Dislocations of the shoulder. M .: Medicine, 1982, S.157] more perfect than the previous one. A narrow, thin chisel through the middle of the saddle-shaped pressed-in defect pierces a narrow gap in the thickness of the dense wall. Then they penetrate and deepen on both sides from the gap to the border with the normal bone. Bone walls, cut off from below, in the form of two cusps retaining tissue connection along the remaining whole, the fourth side of the cusp is raised to the level of the normal surface of the head. Raised in this way, two bone sashes resemble the roof of a house. An autograft is taken from the iliac wing, it is cut into thin cubes and filled with them under the "roof of the house". Under it, previously dissected edges of fibrous tissues and fibers of the adjacent deltoid muscle are sutured.

The disadvantages of the method: increased injuries of the operation (ilium), the complexity of the transposition of the tendon of the biceps muscle with large defects.

A further improvement of the method is the use of porous titanium nickelide as an implant material replacing a bone defect [A. B. Kazantsev, I. R. Kuzina, S. A. Cherkasova. Methods of surgical treatment of impression fractures of the shoulder. // Actual issues of implantation and osteosynthesis. Novokuznetsk - St. Petersburg, 2001, S.15-16]. Depending on the characteristics of the defect, the method varies by methods of restoring the normal surface of the head and filling the resulting void with an implant. An illustration is the plasticity of a large tubercle (figure 2). After osteotomy of the defect, the cavity formed is filled with a porous nickelide titanium implant, which is simulated as much as possible in defect shape. On top of the defect is covered with a fibrous membrane of the type "house roof".

The advantage of this method is the reduction of trauma and the time of surgical intervention, the simplification and aesthetics of the operation, its implementation from relatively gentle incisions.

The disadvantages of this method are the impossibility of lifting osteotomy with a large size of the impression defect, the difficulty of modeling anatomically adequate implants, the low reliability of the restored joint due to wear (grinding on the roughness of the implant) of the bone “wings” and subsequent prolapse of the implant.

This analogue is selected as a prototype by the greatest similarity.

The technical result of the invention is to increase the viability of the operation.

The specified technical result is achieved by the fact that in the method of plastics of impression defects of the humeral head, including preparatory osteotomy of the defect cavity, filling the prepared cavity with a replacement implant from porous titanium nickelide, fixing and covering the replacement implant, a replacement implant is used in the form of a granular mixture of granules of porous titanium nickelide and bone fragments of an impression defect; a replacement implant is fixed by layer-by-layer covering of it in the defect cavity with a plate made of drill elastic porous titanium nickelide, tendon-capsular tissues of the shoulder joint and compress the formed composite brackets of titanium nickelide.

The attainability of the technical result is due to the separate and combined action of the essential features of the method, namely:

1. The main effect - fast and low-relapse healing of a bone defect - is created by the properties of the replacement material. Granular porous titanium nickelide in a mixture with bone fragments of the defect forms an easily modeled, adequate in defect shape, replacing the volume of the implant. The surgeon’s work is simplified, the intimacy of the replacement material and the defect wall increases. The latter contributes to the speedy impregnation of the implant with body fluids and the further process of osteosynthesis. By biocompatibility, titanium nickelide is progressive among modern analogues. Osteosynthesis in a mixture of titanium nickelide with autologous fragments is even more intense.

The optimal granule sizes of 0.1-2.0 mm titanium nickelide were selected empirically according to the results of the viability of the operation and the healing time.

Shelter implanted in the cavity of the defect of the bulk material is carried out, firstly, a plate of porous titanium nickelide. The elastic properties of this material with the proper minimum plate thickness provide for the formation of the convex surface of the shoulder head.

The tendon-capsule tissues superimposed on top and the compression bracket complete the stable fixation of the implant, provide intensive osteosynthesis and improve the anatomical and functional outcomes.

These positive consequences in a generalized form in comparison with the prototype are interpreted as increasing the viability of the operation. The accompanying technical result is the simplification and facilitation of the surgeon's work.

A new set of distinctive features, the absolute novelty of the feature — the use of a granular mixture of titanium nickelide granules and bone fragments to replace a complex shape defect — indicates that the proposal meets the criterion of "inventive step".

The illustrations show:

Figure 1. Plastic surgery of a fresh impression fracture of the humerus head by raising the bottom of the defect.

Figure 2. Plastic surgery of an impression fracture of the humeral head with a replacement implant.

Figure 3. Appearance of an impression fracture of a large tubercle of the humeral head.

Figure 4. A fragment of the operation. 1 - cavity of the bone defect, 2 - tissue tendon-capsule complex, 3 - tendon of the long head of the biceps muscle.

Figure 5. Replacement implant and defect cover plate.

6. Scheme of the completed operation. 4 - bracket.

As a specific example of the implementation of the method and the attainability of the technical result, a description of the operation is proposed - plastic surgery of an impression-comminuted fracture of the shoulder head performed in the clinic of traumatology and orthopedics of the Novokuznetsk GIDUV.

Patient D., 42 years old, was admitted to the clinic 6 months after the injury. The operation was carried out using a mixture of granular porous titanium nickelide with a predominant granule size of 0.5-2.0 mm and sequestered fragments of an impression defect in a proportion of about five to one.

The method is as follows:

Under anesthesia with front access, the shoulder joint was exposed, its arthrotomy was performed with intersection of the subscapularis muscle 2 and the tendon 3 of the long head of the biceps muscle of the shoulder. During the audit, an impression defect 1 was determined with a size of 3 × 2 cm in scars in the region of the large tubercle and the inter-tubercle groove (Fig. 4). At the bottom of the defect, patches of hyaline cartilage are mosaic.

After transposition according to S.S. Tkachenko, the biceps tendon is pulled to the side to protect it from damage and ease of sequestration of the defect cavity (Fig. 4), the latter is filled with the indicated implant (Fig. 5) to the level of the porous titanium nickelide plate location flush with normal shoulder surface. The tendon of the subscapularis muscle is stitched and fixedly fixed with a bracket 4 of titanium nickelide in the crest of a large tubercle with overlapping area of the remodeled head (Fig.6). The wound is sutured in layers, drained. The limb is laid on a wedge-shaped pillow and fixed with a plaster cast for 4 weeks. After removing the plaster cast, an X-ray control was carried out and a comprehensive physiotherapy exercise was started.

The restoration of the functions of the shoulder joint in the absence of postoperative complications and complaints of the patient indicate the efficiency of the method, a comparative technical result and, in general, the proposal meets the criterion of "industrial applicability".

Claims (1)

The method of plastics of impression defects of the humeral head, including preparatory osteotomy of the defect cavity, filling the prepared cavity with a substitute implant from porous titanium nickel, fixing and covering the substitute implant, characterized in that they use a substitute implant in the form of a granular mixture of granules of porous titanium nickelide with dimensions of 0.1 -2.0 and bone fragments of the impression defect, fix the replacement implant by layer-by-layer covering it in the cavity of the defect with a plate of superelastic por of NiTi, tendon-humeral joint capsular tissue is compressed and formed by composite straps of TiNi.

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