RU2357690C2 - Method of ankle fusion - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention pertains to medicine, namely to traumatology and orthopedics; and may be used in medical treatment of arthrosis of ankle-joint of various etiology. Cartilaginous tissue of articular surfaces is removed. Additionally a slot is made in the cortical layer of the shin bone to the posterior wall of the marrowy channel along with the articular surface of the bone and a channel in the body of talus, whereat autotransplant is 1-2 mm wider than the width of bone bed. Then cortical-tubular transplant is immersed from the wing of ilium into the created slot and channel.

EFFECT: recuperation of the support ability of extremity, stabilisation of the joint, formation of bone regenerate in the defect zone, fast engraftment, increased strength of the fixation of the transplant, increased contact area with fixation site, prevention of post-surgical complications, shortening of the duration of treatment.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the surgical treatment of arthrosis of the ankle joint of various etiologies.

Known methods of arthritis and arthrodesis of the ankle joint, proposed for the treatment of congenital pes aequinus and post-traumatic arthrosis:

1. The method of anterior arthritis according to Conforti (Boychev B., Conforti B., Chokanov K. Operative orthopedics and traumatology. - Sofia: “Medicine and physical education”, 1962, p.832, P.715).

2. The method of Putti arthrodesis (Boychev B., Conforti B., Chokanov K. Operative orthopedics and traumatology. - Sofia: “Medicine and physical education”, 1962, p. 832, S.724).

3. The method of arthrodesis of the ankle joint (Campbell's Operative Orthopedics. V-1. Saint Sais, 1963. P.619-706).

The disadvantages of methods 2 and 3 are the use for arthrodesis of a dystrophically altered anterior lower cortical layer of the distal epiphysis of the tibia, insufficient stabilization of the joint, which leads to a long reconstruction of the graft and its frequent fractures, as well as resorption, even under prolonged, up to 6 weeks, immobilization with a plaster cast. These shortcomings have little effect on the results of treatment in children, but, according to the authors of the application, they limit the use of methods in adults, especially in conditions of arthrosis of the ankle joint (Nikitin G.D., Cancer A.V., Linnik S.A. et al. Bone and muscle-bone grafting in the treatment of chronic osteomyelitis and purulent false joints. - St. Petersburg: "League", 2002. - P.185, C.115).

At the same time, the strength, plastic, and osteogenesis-stimulating properties of autografts from the iliac wing are widely known (Nikitin G.D., Cancer A.V., Linnik S.A. et al. Bone and muscle-bone plastic in the treatment of chronic osteomyelitis and purulent false joints. - St. Petersburg: "League", 2002. - S.185, S.59, 60, 107).

As a prototype for the closest technical essence, we have chosen the method of anterior ankle arthrodesis according to Conforti (Boychev B., Conforti B., Chokanov K. Operative orthopedics and traumatology. - Sofia: “Medicine and physical education”, 1962, p. 832, C .713).

The method consists in fixing with screws to the front surface of the tibia and the body of the talus of the cortical-spongy autograft from the iliac wing after removal of the cartilage of the articular surfaces.

The disadvantages of this method, as practice has shown, are:

- the inability to close the graft of the required size with soft tissues of the anterior surface of the lower leg in the ankle joint;

- the inability to quickly rebuild the graft due to small contact with the tibia and the body of the talus and joint instability after plasty;

- long-term immobilization with a plaster cast - up to 16 weeks;

- risk of transplant resorption;

- the possibility of postoperative complications, such as necrosis and suppuration.

The objective of the invention is to increase the strength of fixation of the graft, reducing the treatment time, as well as reducing the risk of postoperative complications.

The technical result of the invention is to ensure optimal reconstruction of the graft by creating conditions of close contact with surrounding tissues.

The technical result is achieved by forming a cortical-spongy graft from the iliac wing and removing cartilage of the articular surfaces. A groove is formed in the cortical layer of the tibia to the posterior wall of the medullary canal together with the articular surface of the bone, after which a canal is formed in the body of the talus, and the autograft is 1-2 mm wider than the width of the bone bed. Then the transplant is immersed in the formed groove and channel.

The method is as follows.

An anterior surface of the distal tibial epiphysis, a line of the ankle joint and part of the anteroposterior talus within its articular surface are laid out in a linear section 8–10 cm long. The periosteum, the capsule of the joint exfoliate. Cartilages of adjacent articular surfaces and, if possible, the ankle lateral surfaces are removed. Using an electric saw or an ultrasonic saw, a groove is cut out in the cortical layer of the tibia 5 × 1 × 1.5 cm to the posterior wall of the medullary canal together with the articular surface of the bone. A channel is formed with a hand drill in the body of the talus with a diameter of 10 mm and a depth of 2 cm. The foot is set at an angle of 95 ° relative to the lower leg and a cortical-spongy autograft from the iliac wing is firmly inserted into the formed bed 1-2 mm wider than the size of the bone box. The front edge of the graft should coincide with the front surface of the tibia. The wound is well stitched, after which the periosteum, aponeurosis and skin are restored by applying knotted sutures. Immobilize the wound with a U-shaped plaster cast until the wound heals, and then apply a circular plaster cast of the “boot” type to the upper third of the leg for 8 weeks. The load on the leg is allowed from the end of 6 weeks after surgery.

Distinctive essential features of the proposed method are:

- the formation of a groove in the cortical layer of the tibia to the posterior wall of the marrow canal together with the articular surface of the bone;

- channel formation in the talus;

- the graft is 1-2 mm wider than the width of the groove;

- immersion of the graft in the formed groove and channel.

The causal relationship between the essential distinguishing features and the achieved result is as follows.

The formation of a groove in the tibia and the canal in the talus allows you to immerse the graft in the bone marrow canal of the bones, which ensures the strength of the fixation of the graft and increases the contact area with the fixation of both the graft and the ankle joint. Joint and graft stability is also achieved by the fact that the graft is 1-2 mm wider than the width of the groove. Strong fixation and an increase in the contact area contributes to the rapid germination of the graft by the vessels and its optimal restructuring with the formation of a bone block in the joint. Soft tissue in the area of the operation does not experience transplant pressure and sutures without tension. Suturing a wound without tensioning the soft tissues eliminates the risk of complications in the form of necrosis and suppuration.

The set of distinctive essential features is new and provides stable fixation of the graft to the place of transplantation and creates the conditions for close contact of the graft with surrounding tissues, which contributes to more rapid germination of the graft by the vessels and its optimal restructuring with the formation of a bone block in the joint, which, in turn, shortens the time treatment and reduces the risk of postoperative complications, such as necrosis and suppuration, as well as in the long term eliminates the risk of transplant resorption.

We give examples from clinical practice.

Example No. 1. The medical history No. 17649. Patient N., 68 years old.

He entered the clinic of traumatology and orthopedics of the hospital. Emperor Peter the Great with a diagnosis of Post-traumatic deforming arthrosis of the right ankle joint, subluxation of the foot outside. A history of pronational damage to the ankle joint, subluxation of the foot out. Treated in a city hospital - manual reposition. Plaster cast up to 12 weeks. The purpose of hospitalization: pain, inability to support the right foot. 12/13/05 operation: "Arthrodesis of the right ankle joint with an autograft from the iliac wing." Under spinal anesthesia, a linear incision along the anterior surface of the lower third of the right lower leg with a partial transition to the rear of the foot reveals the corresponding surfaces of the tibial epiphysis, ankle joint and the upper articular part of the talus. The joint is opened. Cartilaginous plates and scars of adjacent articular surfaces, as well as both ankles were removed, after which the subluxation of the foot was partially eliminated. In the epiphysis of the tibia, a groove of 5 × 1 × 2 cm is formed to the posterior wall of the bone. The resulting bone fragment along with its articular part was removed. A channel 1 × 2 cm is formed in the adjacent surface of the talus with a hand drill.

A cortical-spongy autograft from the anterior iliac wing 7 × 1.2 × 2 cm, prepared at the first stage of the operation, was tightly driven into the resulting bed, so that the foot was at an angle of 95 °. Joint and graft stability is achieved in that the graft is 2 mm wider than the groove width. The wound is washed. The bone fragment obtained during the formation of the groove is crushed and also tightly fixed along the joint line. Layered seams on soft tissue. Before removing the sutures (12 days) - immobilization with a U-shaped plaster cast, and then a circular plaster cast is applied to the knee joint for 8 weeks. The load on the leg is allowed from the end of 6 weeks after surgery. After 8 weeks, the bandage was removed. On the control x-ray - held bone block of the ankle joint. When viewed after 3 months - no complaints, walks with a full load.

Example No. 2 (by the prototype method). Medical history No. 12036. Patient S., 52 years old.

He entered the clinic of traumatology and orthopedics of the hospital. Emperor Peter the Great with a diagnosis of Post-traumatic arthrosis of the left ankle joint. A history of pronational damage to the ankle joint 2 years ago. Cannot walk due to severe pain. Conforty surgery was performed under spinal anesthesia. However, when trying to close the transplant with soft tissues, it turned out that there is a skin deficiency. The transplant is thinned, but the remaining mass is not enough to form a good bone block of the joint. In order to eliminate the risk of increased tension of the skin, its necrosis and suppuration, Campbell's arthrodesis was performed, and a transplant from the iliac wing in the form of a crumb was rammed along the lateral surfaces of the articular surface of the talus. Before removing the sutures - immobilization with a U-shaped plaster cast, and then with a plaster “boot” for 14 weeks. The leg load is allowed from the end of 10 weeks after surgery. When viewed after 6 months - no complaints. It goes with a full load. On radiographs - the bone block of the left ankle joint.

According to the claimed method, 12 patients were operated on. The age of patients is from 42 to 76 years.

In 8 patients, surgery was undertaken for post-traumatic arthrosis, in two - an age factor, and in two - after purulent arthritis. No complications were noted in any case. Bone block in all patients occurred in the period from 8 weeks (10 people) to 10 weeks (2 patients). Even in patients with sluggish nonspecific arthritis, the total treatment time was 8-10 weeks, and in no case were there fractures or resorption of grafts.

According to the prototype method, only one patient was operated on, since, according to the authors of the proposed method, the prototype method is difficult because of the impossibility of closing the transplant of the required size with soft tissues of the anterior surface of the lower leg in the ankle joint. When you try to perform an operation according to the prototype method, there is a risk of skin necrosis and suppuration. The terms of treatment according to the prototype method described by B. Boychev et al., Up to 14 weeks.

The inventive method of arthrodesis of the ankle joint provides stable fixation of the graft to the site of transplantation and creates conditions for the graft to come in close contact with surrounding tissues, which contributes to more rapid germination of the graft by the vessels and its optimal restructuring with the formation of a bone block in the joint, which, in turn, reduces the risk of postoperative complications such as necrosis and suppuration, as well as in the long term, eliminates the risk of transplant resorption. The total treatment time compared with the prototype method is reduced by 4-6 weeks.

Claims (1)

The method of ankle arthrodesis, including bone autoplasty with a cortical-spongy graft from the iliac wing and removal of cartilage of the articular surfaces, characterized in that they additionally form a groove in the cortical layer of the tibia to the posterior wall of the bone marrow canal together with the articular surface of the bone and the channel in the body the talus, and the autograft is 1-2 mm wider than the width of the bone bed, then the graft is immersed in the formed groove and channel.