RU2352279C2 - Method of osteosynthesis at compression fractures of tibial bone condyles - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine area, namely, traumatology. Corticotomy is made in a cortical layer of the broken condyle of a tibial bone and reposition of an articulate platform by excess of an osteal tissue by creasing of a cortical plate of the broken condyle of the tibial bone in a direction of a compressed site before restoration of an articulate surface under the arthroscope control. Thus fracture bracing is made by carrying out of not less than three crossing Kirschner wires through a proximal metaphysis of a tibial bone in a subchondral layer of the bone and a reduced articulate platform with excess of the osteal tissue, fixed in the apparatus of external bracing. And the support platforms of two of them are located on the different sides from fracture, and a crossing of the spokes is placed out of the fracture zone. Then, the crossing Kirschner wires are pulled through a distal metaphysis of the tibial bone and through a proximal third of diaphysis below tuberosity of the tibial bone. The apparatus of external bracing is mounted using three legs.

EFFECT: use of the given invention allows achieving stable interfragmentary compression in a fracture zone, to frame an adequate leg for maintenance of the broken condyle, to prevent gonarthrosis development in the remote period.

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Description

The invention relates to medicine, namely to traumatology.

All over the world there is a high level of injuries (Yumashev G.S. 1990). Intra-articular injuries of the knee joint are more and more common (Khabirova G.F., Shatrukov L.F. 1980). Intra-articular fractures of the knee joint are among the most severe injuries of the musculoskeletal system, ranging from 3.7 to 9.4% (an average of 6.9%) among other bone fractures, affecting people of working age (Mikhailenko V.V. 1995) . Any significant displacement of the articular surface during various fractures of the condyles of the tibia requires an open reposition and adequate internal fixation (Muller M.E., Allgover M., Schneider R., Willenger X. 1996).

Existing methods of osteosynthesis for isolated fractures of the tibial condyles do not always ensure restoration of joint congruency, creation of adequate support to maintain a broken condyle of the tibia and preservation of congruence of the articular surface during patient rehabilitation, require the use of gypsum immobilization in the postoperative period, which contributes to the development of stiffness of the knee, require the use of grafts.

A known method of osteosynthesis using an AO / ASIF support plate. Access is made, the articular surface is exposed and examined. After reposition of the articular surface, temporary fixation with one or more Kirchner spokes is performed. The resulting defect in the tibial metaphysis is filled with a spongy bone, which supports the raised articular surface. Osteosynthesis is completed by the addition of a support plate. The spokes are removed. The plate is fixed with screws inserted through the reponent condyle and the lower tibia (M.E. Muller, M. Allgover, R. Schneider, X. Willenger. Manual on internal osteosynthesis. - M.: Ad Marginem, 1996. p. 568-571, Fig. 13.12 e, d; 13.14).

The disadvantages of this method:

- does not always provide restoration of joint congruency;

- adequate support is not created to maintain a broken tibial condyle;

- requires the use of an autograft, which contributes to an increase in the volume of surgery and a cosmetic defect;

- autograft resorption and insufficient vascularization of the tibial plateau leads to subsidence of the articular surface in the postoperative period, in the process of patient rehabilitation.

Closest to the claimed is a method of osteotomy for isolated fractures of the external condyle of the tibia. The anterior external arcuate access exposes the upper third of the tibia, the flexors of the foot are separated from the external condyle by a raspator. Using a circular cutter, a corticotomy is performed in the cortical layer of the outer condyle of the tibia. Under the control of an arthroscope, using a tamper, the cortical plate of the outer condyle of the tibia is crushed in the direction of the compressed area. The articular platform of the external condyle is raised to the level of the lower edge of the external meniscus, thereby forming an excess of cancellous bone tissue under the cortical plate of the joint plate of the tibia, which subsequently undergoes faster revascularization. The resulting defect is filled with a cylindrical porous implant (in sizes corresponding to the diameter of the cutter used) of titanium nickelide, thereby creating a stable basis for the raised joint area of the tibia. The wound is sutured in layers, drained by rubber graduates, gypsum immobilization (US Pat. RF No. 2161457, class A61B 17/56, A61L 27/06 "Method of osteotomy for isolated compression fractures of the external condyle of the tibia", publ. 10.01.2001. Bull. No. 1, p. 277).

The disadvantages of this method:

- restoration of joint congruency is not always ensured;

- the lack of fixation of the graft can lead to its secondary displacement and loss of congruence of the articular surface;

- requires the use of gypsum immobilization in the postoperative period, which contributes to the development of stiffness of the knee joint;

- requires the use of a titanium-nickelide graft, as a result of which an unremovable metal foreign body remains in the bone tissue, which may interfere with therapeutic (UHF, radiation therapy) and diagnostic (magnetic resonance imaging) measures after the fracture is consolidated and treatment is completed.

The objective of the present invention is to develop a method for restoring joint congruency, creating adequate support for maintaining a broken condyle of the tibia and maintaining congruence of the articular surface during rehabilitation of a patient who does not require the use of gypsum immobilization in the postoperative period, and refusal to use grafts.

This object is achieved by performing a corticotomy in the cortical layer of the broken condyle of the tibia and repositioning the articular site with excess bone tissue by crushing the cortical plate of the broken condyle of the tibia in the direction of the compressed area until restoration of the articular surface under the control of the arthroscope. The fracture is fixed by passing through the proximal tibia metaphysis in the subchondral layer of the bone and the repaired articular site with excess bone tissue of at least three Kirschner crosses fixed in the external fixation apparatus, two of which with persistent sites, are located on opposite sides of the fracture, and the crossing of the spokes is located outside the fracture zone.

The novelty of the method is as follows.

1. The fracture is fixed by passing through the proximal metaphysis of the tibia in the subchondral bone layer and the repaired articular site with excess bone tissue of at least three Kirschner crosses fixed in the external fixation apparatus, two of them with persistent platforms located on opposite sides from fracture, which allows for stable fixation of the fracture and create interfragmental compression in the fracture zone.

2. Cross Kirschner knitting needles are placed outside the fracture zone, which creates adequate support for maintaining a broken condyle of the tibia and allows maintaining congruency of the articular surface during the patient's rehabilitation.

The set of essential features of the proposed method allows:

- due to crushing the trabecular bone of the broken condyle in the direction of the compressed area under the control of an arthroscope, reposition the articular surface;

- by holding Kirschner spokes in the proximal tibia metaphysis through the subchondral layer and creating lateral compression of the fragments, support is achieved for the broken condyle of the tibia, which ensures the preservation of congruence of the articular surface during patient rehabilitation;

- abandon the use of transplants, which helps to reduce the volume of surgery (when using autografts), and avoids leaving unremovable foreign bodies in the bone tissue, such as transplants from titanium nickelide;

- stable osteosynthesis and rejection of gypsum immobilization allows you to start movement in the joint early after surgery, which prevents the development of stiffness of the knee joint.

The invention is illustrated by drawings, where figure 1, 2, 3, 4 - shows the steps of the operation.

The essence of the method is as follows. An arthroscope is inserted into the cavity of the knee joint. The joint is washed from blood clots and fragments of cartilage. The joint is revised and interventions are made for collateral damage to the meniscus or ligamentous apparatus. The fracture site is visualized. Extraarticular access is performed. The upper third of the tibia is exposed. Using a raspator, soft tissues are separated from the condyle. Having retreated approximately 4 cm from the articular surface, using a circular cutter or osteotome, a corticotomy (1) is performed in the cortical layer of the broken condyle of the tibia. Under the control of an arthroscope, using a tamper (2), the cortical plate of the outer condyle of the tibia is crushed in the direction of the compressed area (3). The joint space of the tibial condyle is raised until the joint surface of the fractured tibial condyle is congruent, thereby creating an excess of cancellous bone tissue under the cortical plate of the joint plate of the tibia (4), due to crushing of the cancellous bone of the broken condyle in the direction of the compressed area, and which later it undergoes revascularization faster. After reposition of the articular surface through the proximal metaphysis of the tibia, in the subchondral layer of the bone, at least three Kirschner crossing needles (5) are carried out, creating support for the restored articular surface. Two of Kirschner spokes (5) with thrust pads (6) to create an on-side compression in the fracture zone are carried out as follows: one spoke is directed from the outside to the inside, the second from the inside out. The third spoke (5) is held at the same level as the knitting needles (5) with thrust pads (6), while the point of intersection of the knitting needles (7) is located outside the fracture zone (8). Two Kirschner knitting needles (5) are passed through the distal tibia metaphysis and through the proximal third of the diaphysis below the tibial tuberosity. An external fixation apparatus of three ring supports connected by threaded rods is mounted. The spokes are pulled and fixed to the annular supports of the apparatus according to the level of conductivity, and the spokes (5) with thrust pads (6) are pulled to create counter-lateral compression (the direction is indicated by the arrow) and are fixed to the proximal ring of the external fixation apparatus. To the same ring is fixed after tensioning the spoke (5) without a thrust pad. The wound is sutured in layers. Due to stable osteosynthesis by an external fixation device, additional immobilization in the postoperative period is not required. Passive movements in the knee joint begin from the first day. Dosed load is allowed after 6 weeks, complete 12 weeks after surgery. Defect (9) is filled with spontaneous bone regenerate. Dismantling of the external fixation apparatus is carried out after the joint of the fracture, 10-12 weeks after surgery.

Clinical examples.

Example. Patient M. Was admitted to the clinic 01/31/2004. with a diagnosis of Closed compression fracture of the external condyle of the tibia of the left leg. After preoperative preparation, 02.02.2004. the patient underwent surgery: Arthroscopy of the left knee joint, reposition, osteosynthesis of the external condyle of the tibia.

Under conduction anesthesia, under a tourniquet, the surgical field is twice treated with a solution of iodovidone. Arthroscopy was performed through standard approaches, the joint was washed away from blood clots and fragments of cartilage. Impression of the articular surface in the region of the inner condyle of the tibia was revealed. Extraarticular access was performed, the upper third of the tibia was exposed. Soft tissue is separated from the condyle using a raspator. With the help of the osteotome, having retreated 4 cm from the articular surface, a corticotomy was performed in the cortical layer of the broken condyle of the tibia. Under the control of an arthroscope, using a tamper, the cortical plate of the outer condyle of the tibia is wrinkled in the direction of the compressed area. The elevation of the articular pad of the external condyle was performed until the congruence of the articular surface was restored. After repositioning the articular surface through the proximal metaphysis of the tibia, three intersecting Kirschner spokes were drawn in the subchondral layer of the bone, thereby creating support for the raised articular surface, two of the Kirschner spokes were made with thrust pads to create lateral compression in the fracture zone. The third spoke was drawn without a thrust pad, at the same level as the knitting needles with thrust pad, while the point of intersection of the spokes is located outside the fracture zone. Two cross Kirschner spokes were drawn through the distal metaphysis of the tibia and through the proximal third of the diaphysis below the tuberosity of the tibia. An external fixation apparatus of three ring supports connected by threaded rods is mounted. The spokes are stretched and secured to the annular supports of the apparatus according to the level of conductivity, and the spokes with thrust pads are stretched to create counter-lateral compression to the proximal ring. To the same ring is fixed after tensioning the spoke without a thrust pad. The wound is sutured in layers. The postoperative period was uneventful. Sutures were removed on day 10. Passive movements in the knee joint started from the first day. Dosed load is allowed after 6 weeks, complete 12 weeks after surgery. The external fixation device was removed 10 weeks after the operation, the full range of movements was restored. A follow-up examination 1 year after the injury, the range of motion is complete, there is no pain, radiological signs of arthrosis are not detected, the defect is filled with spontaneous bone regenerate, signs of subsidence of the articular surface were not detected.

Thus, 6 people were operated on. In all cases, a good result was obtained: the full range of movements, the absence of pain, radiological and clinical signs of gonarthrosis were absent. A year later, during the control X-ray examination, the defect was filled with spontaneous bone regenerate, there were no signs of articular subsidence.

Using this method gives the following effect:

- provides restoration of congruency of the joint;

- an adequate support is created to maintain a broken tibial condyle, which helps to maintain congruence of the articular surface during the rehabilitation of the patient;

- the rejection of gypsum immobilization in the postoperative period contributes to the early onset of movements and the prevention of stiffness of the knee joint;

- replacement of the defect with spontaneous bone regeneration eliminates the use of transplants, which helps to reduce the volume of surgery and cosmetic defect (when using autografts), and avoids leaving foreign bodies that cannot be removed in the bone tissue, such as grafts from titanium nickelide;

- early development of movements and the presence of a stable support for the condyle can reduce treatment time by 1-1.5 months, prevent the development of gonarthrosis in the long term.

Claims (1)

A method of osteosynthesis for compression fractures of the tibial condyles, including corticotomy in the cortical layer of the fractured tibial condyle and repositioning of the articular site with excess bone tissue by crushing the cortical plate of the fractured tibial condyle in the direction of the compressed portion until restoration of the articular surface under the control of the arthroscope, the fracture is performed by passing through the proximal metaphysis of the tibia into the subchondra the flax layer of the bone and the repaired articular area with an excess of bone tissue of at least three Kirschner cross knitting needles fixed in the external fixation apparatus, the thrust pad of two of them being placed on opposite sides of the fracture, and the knitting needles are crossed outside the fracture zone, then the Kirschner knitting needles are crossed through the distal metaphysis of the tibia and through the proximal third of the diaphysis below the tuberosity of the tibia, an external fixation apparatus of three supports is mounted.

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