RU2294168C1 - Method for treating patients with severe polytrauma and complicated fractures of long tubular bones - Google Patents

Abstract

FIELD: medicine, traumatology, orthopedics.

SUBSTANCE: in acute period it is necessary to fulfill reposition of the main osseous fragments of affected segment of a limb out of minor surgical access located beyond the area of the fracture. One should fix the fragments with a dowel and block it with screws. The area of the fracture should be opened after improvement of patients' state of health to remove small loose osseous fragments, contrast large intermediate osseous fragments by wrapping the dowel with them in area of defect, fill in the spaces between large osseous fragments with a spongiform allograft by reconstructing osseous diaphysis along screws-blocked dowel. The main osseous fragments, large intermediate osseous fragments and spongiform allograft should be additionally fixed together with a plate and screws. The innovation enables to decrease the risk for failed union of the fracture, provide earlier activation in patients and shorten therapy terms.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, more specifically to traumatology and orthopedics, and can be used to treat patients with severe polytrauma and multiple fractures of long tubular bones with bone defects.

In patients with polytrauma, as a result of a highly kinetic traumatic agent, open and closed complex and multi-fragmented injuries of the long tubular bones of the limbs occur.

A known method of open osteosynthesis with plates of multi-fragmented and complex fractures of the diaphysis in patients with polytrauma, in which the formed defects are filled with a spongy autograft (Guide to internal osteosynthesis / Methodology recommended by the AO group (Switzerland) / M.E. Muller, M. Algover, R. Schneider , H. Willinger // Ad Marginem, Moscow, 1996, p. 535-585).

However, the implementation of open osteosynthesis with multi-fragmented and complex fracture plates is impossible in many cases, which is associated with the general serious condition of the patient. Also, in most cases, the general condition of the patient at an early resuscitation stage does not allow increasing the volume of surgical intervention and lengthening the time of operations associated with taking a bone autograft. The presence of abrasions, superficial wounds, hematomas, and soft tissue bruises in the fracture zone is a contraindication for open plate osteosynthesis due to the high risk of purulent complications.

Known methods for filling defects in bone tissue with allografts:

1. Intramedullary bone grafting;

2. Intra-extramedular bone grafting according to Chaklin;

3. Bone grafting according to the “brushwood” type according to Volkov.

All these methods are used independently without the use of fixation of fragments with metal clips. Immobilization of bone fragments is carried out with a plaster cast or external fixation apparatus (Movshovich I.A. / Operative orthopedics // Moscow, 1983, p.21-31).

A known method of closed osteosynthesis of multi-fragmented and complex fractures of long tubular braids, which are performed from small surgical approaches located outside the fracture zone. In this case, the proximal and distal fragments of bones are connected together by a metal pin, which is inserted into the bone marrow canal, with its proximal and distal blocking by screws. However, intermediate bone fragments located between the proximal and distal fragments often cannot be accurately compared. Small cortical bone fragments, deprived of communication with soft tissues, do not have bone-forming properties and do not participate in fracture fusion. As a result, some patients still have a bone defect, and fracture consolidation does not occur. The larger the defect, the greater the likelihood of nonunion fracture. In this case, after 8-16 months, the blocked pin is removed and repeated fracture osteosynthesis is performed with bone autoplasty plates (Intramedullary osteosynthesis: catalog / Osteomed-M // Moscow, 2002, p. 56; Guide to internal osteosynthesis. / Methodology, recommended by the group of joint-stock companies (Switzerland) / M.E. Muller, M. Algover, R. Schneider, H. Willinger // Ad Marginem, Moscow, 1996, p. 535-585).

The disadvantage of closed osteosynthesis with a pin locked screw, taken as a prototype, is the preservation of a bone defect between the main fragments and large fragments of long tubular bones for a long time, which leads to the formation of nonunions and false joints, which require repeated surgical interventions and extend the treatment time.

The objective of the invention is to optimize the timing of the fusion of multi-fragmented and complex fractures of long tubular bones in patients with polytrauma, reducing the overall duration of treatment and disability.

The problem is solved in that in the method of treating patients with severe polytrauma and complex fractures of long tubular bones, including in the acute period a closed reposition of the main bone fragments of the damaged segment of the limb, made from small surgical accesses located outside the fracture zone, fixing bone fragments with a pin, blocking the pin with screws and, in the presence of a bone defect between the main fragments, after the improvement of the patient's condition, the fracture zone, small free-lying bones are opened the fragments are removed, then large intermediate bone fragments are compared, wrapping them with a pin in the defect zone, and the gaps between large bone fragments are filled with a spongy allograft, reconstructing the bone diaphysis along the screw-locked pin, with the main bone fragments, large intermediate bone fragments and a spongy allograft a plate and screws.

The method is as follows. The patient is placed on an orthopedic table and an indirect closed reposition of the fracture is performed by traction along the axis of the limb. A small surgical approach of about 3 cm long is performed outside the fracture zone, at the level of the proximal or distal segment of the limb segment. From this access, the bone marrow canal is opened. A metal pin is inserted into the medullary canal under the control of an electron-optical transducer (EOP), which is passed through the medullary canals of the proximal and distal fragments. Under the control of the image intensifier tube, distal blocking of the pin with two screws is performed, and proximal blocking of the pin with two screws is performed along the guide. Thus, a strong fixation of the main bone fragments is achieved. The postoperative wound is sutured tightly. The patient is removed from the orthopedic table. After the patient's condition improves (after 2-4 weeks), he is re-operated. The fracture zone and bone defect are opened, small free-lying bone fragments are removed, and large intermediate bone fragments are compared with each other, wrapping a pin in the defect zone. The gaps between large fragments are densely filled with a spongy allograft, reconstructing the diaphysis of the bone along the pin blocked by screws. Then, the main bone fragments, large intermediate bone fragments and a spongy allograft are additionally fixed between themselves by a plate and screws.

Clinical example.

Patient Х-в, 28 years old, medical history No. 13561, was in the Scientific Research Institute of the Joint Venture named after N.V. Sklifosovsky from July 24, 2004 to October 6, 2004

Diagnosis: severe concomitant injury. OMT. A brain injury of moderate severity. Fracture of the anterior cranial fossa. Fracture of the bones of the nose. Closed comminuted fracture of the right femur. Open fracture of the right patella. An open complex fracture of both bones of the right tibia in the middle and lower third. An open complex fracture of the left femur. Fracture of the left femur. Closed chest injury. Bilateral hydrothorax.

An accident as a result of a car accident on July 23, 2004. First aid was provided at the Central Clinical Hospital of Naro-Fominsk, where primary surgical treatment of open fracture wounds, gypsum fracture immobilization was performed, and anti-shock therapy was performed. July 24, 2004 the patient was transferred for further infusion, transfusion, antibacterial, symptomatic therapy. Further examination of the patient: CT scan of the brain, ultrasound of the abdominal and pleural cavities, radiography of fractures of the extremities. For temporary immobilization of fractures, skeletal traction was applied. On July 28, 2004, the patient was taken to the operating room, where the patient underwent the following operation under spinal anesthesia: closed osteosynthesis of the right tibia with a blocked tibial pin, closed osteosynthesis of the right femur with a blocked femur pin. 08/04/2004 closed osteosynthesis of the diaphysis and neck of the left thigh was made with a long proximal femoral pin with locking screws. On the radiograph of the limbs after the operation, the position of the bone fragments and fixators of the right thigh and right lower leg is correct. The left thigh is fixed with a long proximal femoral pin with screw locking, the axis and limb length are restored, however, large intermediate bone fragments are significantly separated from each other. Thus, the defect of the diaphysis of the left thigh was determined, which was an indication for further surgical treatment. On 26.08.2004, after stabilization of the general condition of the victim, restoration of the main indicators of homeostasis and normalization of the skin of the left thigh, the patient underwent surgery under spinal anesthesia - bone alloplasty with spongy lyophilized demineralized and spongy non-demineralized grafts. Small free-lying bone fragments are removed, and large intermediate bone fragments are compared. Defects between fragments are filled with a spongy allograft. An additional fixation of bone fragments and a spongy allograft with a plate and screws was made. The early postoperative period was uneventful. Postoperative wounds healed by first intention. The patient was engaged in physical therapy, activated with a wheelchair. An X-ray of the left thigh eight weeks after the bone alloplasty is performed, massive periostatic callus is determined, covering fixed intermediate bone fragments and the main fragments of the left thigh; signs of bone marrow formation of the right thigh and right lower leg. The patient was trained in walking with additional support on crutches and, in satisfactory condition, was discharged under outpatient supervision of a traumatologist at the place of residence.

The proposed method was applied in five patients with polytrauma and complex fractures of long tubular bones. In all cases, it was possible to achieve the appearance of massive bone callus in the fracture area in the early stages (up to 10 weeks from the moment of injury) with the possibility of early activation of the victim with a load of body weight on the operated limb.

Claims (1)

A method for the treatment of patients with severe polytrauma and complex fractures of long tubular bones, including in the acute period reposition of the main bone fragments of the damaged segment of the limb, made of small surgical access located outside the fracture zone, fixing the fragments with a pin and locking the pin with screws, characterized in that if a bone defect between the main fragments after improving the patient’s condition, the fracture zone is opened, small free-lying bone fragments are removed, then matching large intermediate bone fragments, wrapping them with a pin in the defect zone, and the gaps between large bone fragments are filled with a spongy allograft, reconstructing the bone diaphysis along the pin blocked by screws, and the main bone fragments, large intermediate bone fragments and spongy allograft are additionally fixed between each other with a plate and screws .