RU2309690C2 - Method for treating false joints of tubular bones at cicatricially altered soft tissues - Google Patents

Abstract

FIELD: medicine, traumatology, orthopedics.

SUBSTANCE: it is necessary to apply compression-distraction apparatus of external fixation, carry out close reposition at correcting the deformation and removing a limb's shortening, fulfill osseous-plastic osteostimulation, beyond the area of a limb's compromised tissues one should dissect skin to form periosteal-cortical autotransplants at forming a groove in the bone, drill medullary canal of fragments from the groove developed, introduce autotransplants intraosseously from the developed osseous groove at longitudinal overlapping the area of false joint, form tibial autotransplants being either above or below the area of false joint, form autotransplants at the distance of about 60-100 mm against false joint, cut autotransplants of the width being 10 mm, not more and size of 40×10 mm. On forming one should place autotransplants into heparin solution to steep in heparin for about 30-40 min. Before transplantation autotransplants should be cut into pieces, autotransplants should be segmented into cubes of 10×10 mm. At drilling of medullary canal one should deepen into opposite fragment for about 20-230 mm. In case of rigid forms of false joints it is necessary to carry out close blood-free correction of axial deformation in the apparatus due to distraction for the period of 2-3 wk. One should overlap the area of false joint with autotransplants at 20 mm, not less towards the side of a fragment. The innovation provides stable fixation of fragments, reconstructs anatomical axis of a limb, extrafocal osseous-plastic substitution of the area of pathological process, without dissecting the cicatrices of soft tissues and accelerates osteogenesis of fragments' ends.

EFFECT: higher efficiency of therapy.

10 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of patients with false joints with scarred skin in the zone of classical operative access with a hypotrophic form of callus formation at the junction of the ends of the fragments, accompanied by angular deformation, in traumatological and orthopedic departments hospitals and clinics NIITO.

A known method of treating diaphyseal pseudoarthrosis of the tibia in conditions of scarred soft tissues [US Pat. RU No. 2262317 A61B 17/56 from 2003.09.01, publ. 2005.03.10], including applying a compression-distraction apparatus, performing two tibia osteotomies in it, the first - directly in the synostosis zone with excision of scar-changed soft tissues and subsequent intraoperative simultaneous convergence of fragments until the inter-fragment gap and disappearance in the pseudarthrosis zone disappear, second - distal to the level of the first osteotomy by at least 40 mm and the subsequent uneven dosed distraction with angular displacement of the underlying fragment and correction of deformation, osleduyuschey fixation fragments.

The disadvantages of this method are:

- ineffective in normohypertrophic forms of false joints with violation of vascularization and dystrophy of the bone-periosteal layer;

- high morbidity due to the performance of two osteotomies, excision of soft tissue scars;

- high risk of infection and inflammation due to open intervention in the pseudarthrosis;

- the duration of the healing process.

A known method of treating periarticular false joints of the tibia, combined with a defect in the external departments of its metaphyses [c. RU No. 95120117 А61В 17/56 dated 11.28.1995, publ. 10/01/2001], including an osteotomy of the damaged external parts of the metaphyses of the limb, the imposition of an external fixation apparatus and the metered movement of fragments, followed by compression and fixation of fragments, the formation of an end fragment from the fibula and overlapping of the fragment contact zone.

The disadvantages of this method are:

- irrational with cicatricial changes and compromised skin around the pathological focus;

- high morbidity due to osteotomy of the focus and fibula;

- high risk of infection and inflammation due to open intervention in the pseudarthrosis;

- lack of correction of emerging biomechanical defects;

- the duration of the healing process.

A known method of treating long-growing fractures and false joints of long bones [US Pat. RU No. 2181267 A61B 17/56, s. RU No. 99105382/14 dated 03/18/1999, publ. 04/20/2002], including the imposition of an external fixation apparatus, the osteotomy of the damaged segment of the limb and compression of fragments, a skin incision outside the projection of the pathological zone, detachment of the periosteum above and below the pseudoarthrosis or nonunion no more than 3 cm long, longitudinal bone osteotomy through the pathological zone in two mutually perpendicular planes.

The disadvantages of this method are:

- ineffective in normohypertrophic forms of false joints with violation of vascularization and dystrophy of the bone-periosteal layer;

- high risk of infection and inflammation due to open intervention in the pseudarthrosis;

- high invasiveness of surgical intervention;

- lack of correction of biomechanical limb defects;

- the duration of the healing process.

A known method of treating false joints of long tubular bones [c. RU No. 98106508 А61В 17/56 dated 03/26/1998, publ. 01/27/2000], including stable fixation of fragments, the formation of a periosteal-cortical graft on the vascular pedicle, the allocation of a false joint along the width equal to 1/4-1 / 5 of the bone circumference and the formation of bed fragments equal to the size of the autograft in the cortical plate, fixation of the periosteal cortical transplant in the formed bed and carrying out revascularization of the transplant through the vessels of the recipient region.

The disadvantages of this method are:

- high invasiveness of surgical intervention;

- high risk of infection and inflammation due to open intervention in the pseudarthrosis;

- technological difficulties in plastic surgery of a periosteal-cortical graft on a vascular pedicle;

- the duration of the healing process.

A known method of plasty of false joints with a sliding autograft according to Khakhutov [p.32 Movshovich I.A. Operative orthopedics - M .: Medicine, 1994, 448 p .; Khakhutov Sh.D. New chir. archive, 1924, 9, 2], including dissection of soft tissues and excision of scars at the ends, formation of two transplants, larger 12 × 15 cm in size — on a larger fragment and a short one - on a smaller one, displacement of a larger autograft through the fault line and overlapping it areas of the pseudoarthrosis, short displacement into the defect in the displacement zone of the larger autograft, fixation of the grafts with circular catgut sutures, application of a plaster cast to the bone fusion.

The disadvantages of this method are:

- ineffective in normohypertrophic forms of false joints with violation of vascularization and dystrophy of the bone-periosteal layer;

- high risk of infection and inflammation due to open intervention in the pseudoarthrosis;

- high invasiveness of surgical intervention;

- lack of correction of emerging biomechanical defects;

- the duration of postoperative treatment and development in the joints due to the application of a plaster cast.

A known method of treating a false joint of the leg [US Pat. RU No. 2147845, z. RU No. 97100096 A61B 17/56 of 1997.01.06, publ. 2000.04.27], including the imposition of an external fixation apparatus and the creation of compression at the junction of bone fragments with the introduction of a fragment of a tubular structure into a fragment of a spongy structure of 10 mm or more, the formation of a channel through the fibula and diaphyseal fragment of the tibia at an angle to the long axis of the limb with the creation at the same time, the marginal defect of the cortical layer, the zone of the pseudoarthrosis, metaphysical fragment of the tibia, implantation of a graft into it, then the formation of the second channel in the fibula and tibia nonunion bone above the zone in a direction perpendicular to the long axis of the tibia and the insertion of the graft, holding fibular osteotomy in a horizontal plane at the level of the upper edge of the graft and entered its convergence with the proximal fragment of the tibia graft.

The disadvantages of this method are:

- ineffective in normohypertrophic forms of false joints with violation of vascularization and dystrophy of the bone-periosteal layer;

- high risk of infection and inflammation due to open intervention in the pseudarthrosis;

- high invasiveness of surgical intervention;

- lack of correction of biomechanical limb defects;

- the duration of the healing process.

The closest in purpose and combination of essential features is a method of accelerated fusion of the false joint or bone fragments, including in the presence of interfragmental scar formations and adhesions covering the ends of bone fragments [US Pat. RU No. 2195216 A61B 17/56, s. RU No.2000128563 dated November 17, 2000], including the application of an external fixation compression-distraction apparatus, performing open or closed reposition with correction of deformation and eliminating limb shortening, fixation under conditions of compression osteosynthesis, performing osteostimulation of the false joint region by introducing a fracture or false joint into the region a drug that accelerates bone regeneration, while a mixture of bone marrow of 3-5 ml taken from the condyle of the thigh or ilium is used as such a drug and, and chileotrypsin with a volume of 20-30 ml.

The disadvantages of this method are:

- imperfect and slow bone fusion during interposition of scar formations and adhesions, covering the ends of bone fragments;

- high morbidity and the possibility of infection due to the need for puncture of the bone marrow of the thigh or ilium;

- the duration of the restoration of skin and periosteal defects.

The tasks solved by the invention:

- reducing the morbidity of surgical intervention;

- reduction of the inflammatory process and the possibility of infection;

- stimulation of osteogenesis at the ends of bone fragments.

The solution of the tasks in the complex will accelerate the fusion of fragments or ends of the pseudoarthrosis during the interposition of scar formations and adhesions between bone fragments, which will reduce the staging and treatment time.

To accomplish the tasks in the proposed method for the treatment of false joints of tubular bones with scarred soft tissues, a compression-distraction apparatus for external fixation is installed on the affected limb and a closed reposition is carried out in it with correction of deformation and elimination of limb shortening, osteostimulation of the false joint area is performed, compression and fixation of bone fragments, in contrast to the prototype, additionally carry out osteoplastic osteostimulation, for which there is a compromise outside the zone The limb cut tissues cut the skin and form the periosteal-cortical autografts with the formation of a groove in the bone, drill the bone marrow canal of fragments from the formed groove, autografts from the formed bone groove are inserted intraosseously with longitudinal overlapping of the region of the false joint.

In this case, autografts can be formed above or below the zone of the false joint, for example, at a distance of 60-100 mm from it, from the tibia. Cut out the autograft rationally with a width of not more than 10 mm and a size of about 40 × 10 mm, while a groove is formed in the bone. After the formation of the autograft, it is advisable to place it in a heparin solution for 30-40 minutes to wash away the remaining blood, and cut it into pieces, for example, into 10 × 10 mm cubes, before transplantation. The drilling of the closed bone marrow canal of fragments is carried out from the formed groove. When drilling it, it is advisable to delve into the opposing fragment by 20-30 mm. In this case, autografts are also rationally administered from the resulting bone groove using a special tool. With intraosseous administration of autografts, the region of the pseudoarthrosis is blocked with at least 20 mm per side.

With rigid forms of false joints, it is necessary to carry out a closed bloodless correction of axial deformation in the apparatus by distraction for 2-3 weeks.

The proposed method differs from the prototype:

- the choice of the incision site of soft tissues;

- harvesting a graft on one of the fragments away from pathology;

- extra-focal opening of the end plates of the ends of the fragments;

- intraosseous overlapping of the pathology zone with autografts.

The proposed method allows you to go to a new level and quality of treatment for patients with false joints of tubular bones with interposition of scar formations and adhesions between bone fragments by accelerating fusion without opening (open intervention) of the false joint by the combined use of extra-focal compression-distraction osteosynthesis and bone-plastic stimulation including extra-focal opening of end plates of fragments of fragments and intraosseous overlap of the area of the false joint periosteal-cortical GOVERNMENTAL autografts.

Early activation of the patient and reduction of treatment time is achieved:

- stable fixation of fragments without fracture in the graft area;

- extra-focal osteoplastic replacement of the area of the pathological process without plastic preparation of the skin;

- stimulation of reduced blood supply to the ends of fragments and osteogenesis;

- equalization of intraosseous pressure in the fragments, which improves the revascularization of the ends of the fragments and accelerates the evolution of autografts, the mineral-protein complexes of which in turn stimulate the bone formation process.

The proposed method is a detailed description of the clinical example and radiographs of the affected limb of patient C. during treatment:

Figure 1 - radiograph of the false joint before treatment;

Figure 2 - x-ray of a limb during surgery;

Figure 3 - x-ray of a limb a month after surgery;

Figure 4 - radiograph of the limb 3 months after surgery;

Figure 5 - radiograph of a limb one year after surgery.

The method is carried out in the following sequence:

The operation is performed under spinal anesthesia in the position of the patient on the back. An Ilizarov apparatus of 3-4 rings is placed on the shin. One of them can be open and consist of a 3/4 ring for the convenience of drilling the marrow canal and the introduction of autografts.

When the apparatus is applied, axial deformation is eliminated and bone fragments are aligned coaxially so that the axis of opposition of the fragments coincides with the longitudinal axis of the tibia. The longitudinal axis of the lower leg can be leveled with an osteotomy of the fibula, preferably in the area of its irregular fusion. With rigid forms of false joints, a bloodless correction of axial deformation in the apparatus can take 2-3 weeks.

After restoration of the anatomical axis of the limb, compression and fixation of bone fragments is performed. The confrontation of fragments and the condition of the bone marrow canal is controlled radiologically

Then, outside the zone of compromised tissues, for example, at a distance of 60-100 mm from the false joint, a skin incision is made and bone grafts are formed from the cortical layer of the tibia about 40 × 10 mm in size. They are removed and placed in a heparin solution for 30-40 minutes, then cut into pieces. From the groove formed in the bone, the bone marrow channel of bone fragments is drilled to a diameter of 10 mm. Using a special tool, autograft slices are intracostally inserted from the groove in the tibia so that the area of the false joint is evenly overlapped, for example, 20 mm to the side of each fragment.

In the postoperative period after the relief of pain - a full load on the limb.

Example 1. Patient S. 21 years old (medical history No. 2816), disabled person of 2 groups. Received an injury to the bones of the lower leg while performing a duty. Within 2 years, he underwent 4 operations. Formed a defect of the tibia in the form of a false joint (figure 1). In the zone of defect-pseudoarthrosis, soft tissues are scarred.

In SarnIIITO a year ago, the patient underwent surgery according to the proposed method (figure 2). On the shin superimposed spoke-rod apparatus. Deformation of the limb was corrected in the apparatus, for which an osteotomy of the fibula was performed simultaneously at the level of its irregular fusion and the confrontation of fragments of the tibia was improved, after which the fragments were compressed. Then, outside the scarred skin, access was made to the tibia and its trepanation for 60 mm. The formed autograft is placed in a heparin solution, then fragmented into 10 × 10 mm pieces. From the resulting grooves, the bone marrow channels of the fragments were opened, and bone tissue was introduced into them intraosseously. Sutures were laid in layers on the surgical wound.

In the postoperative period, the patient is activated, from the 4th day a full load on the limb. The duration of treatment in a hospital is 10 days. A month later, a control radiography (Fig. 3) of the fusion process was carried out. After 3.5 months, the apparatus was dismantled, disability was restored (figure 4). A year later, in the area of the defect-pseudoarthrosis, fusion with the remodeling of bone tissue and grafts was noted (Fig. 5).

Medical and social effectiveness of the method is:

- in the early restoration of the supporting function of the limb (with a full load on the limb after 4-6 days);

- in improving the functional results of treatment;

- reduction of disability and quick rehabilitation of persons with disabilities.

Claims (11)

1. A method of treating false joints of tubular bones with scarred soft tissues, including applying a compression-distraction apparatus for external fixation, conducting a closed reposition with correction of deformation and eliminating shortening of the limb, osteostimulation of the false joint, compression and fixation of fragments, characterized in that osteoplastic osteostimulation, for which, outside the zone of compromised tissue, the limbs cut the skin and form periosteal-cortical autografts with calling a groove in the bone, the bone marrow channel of the fragments from the formed groove is drilled, autografts from the formed bone groove are inserted intraosseously, with longitudinal overlapping of the pseudoarthrosis. 2. The method according to claim 1, characterized in that form autografts from the tibia above or below the zone of the pseudoarthrosis. 3. The method according to claim 1, characterized in that autografts are formed at a distance of 60-100 mm from the pseudoarthrosis. 4. The method according to claim 1, characterized in that autografts are cut out with a width of not more than 10 mm and a size of 40x10 mm. 5. The method according to claim 1, characterized in that after the formation of autografts are placed in a solution of heparin. 6. The method according to claim 5, characterized in that the autograft is soaked in heparin for 30-40 minutes. 7. The method according to claim 4, characterized in that prior to transplantation, autografts are cut into pieces. 8. The method according to claim 7, characterized in that the autografts are segmented into 10x10 mm cubes. 9. The method according to claim 1, characterized in that when reaming the bone marrow canal, they deepen into the opposing fragment by 20-30 mm. 10. The method according to claim 1, characterized in that with rigid forms of the false joints, a closed bloodless correction of axial deformation in the apparatus by distraction is performed for 2-3 weeks. 11. The method according to claim 1, characterized in that they cover the pseudoarthrosis region with autografts of at least 20 mm to the side of the fragment.

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