RU2360632C1 - Way of single-step constrained osteal autoplasty at defects and nearthroses of both bones of forearm - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns traumatology and orthopedy and can be applicable for a single-step constrained osteal autoplasty at defects and nearthroses of both bones of a forearm. Two blood supplied an osteal autografts are allocated from a radial bone - from area of a distal metaepiphysis and from a site on border of a proximal and average third of radial bone - on a uniform proximal vascular leg a-radial vascular fascicle. Osteal autografts are moved with conservation of feeding vessels and fix them in zones of damages of radial and ulnar bones.

EFFECT: way allows replacing single-step defects of radial and ulnar bones with grafts with good blood supply.

1 ex, 7 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used to eliminate defects or in the treatment of false joints of both bones of the forearm.

A known method of free bone grafting with a non-blood-supplying bone autograft with the aim of replacing a bone defect or eliminating a false joint [4, 6], which can be considered as an analogue. The specified method provides a transplant into the region of the defect of a fragment of the patient’s own bone with pronounced osteoinductive properties. However, the method under consideration also has a number of significant drawbacks. In particular, the transplantation of a non-blood-supplied bone autograft into a weakly vascularized recipient bed requires a long fixation of the damaged segment of the limb, and a long reconstruction of the transplanted bone is often accompanied by complications such as suppuration, fracture, or even complete resorption of the graft [1, 3, 4].

The aforementioned disadvantages are deprived of the known method of free bone autoplasty with a blood-supplied bone graft, which can also be considered as an analogue of the proposed method [3, 5]. However, it should be noted that in this case, a blood-supplying bone autograft is transplanted into the reconstruction zone as part of a complex of tissues on its own feeding vascular pedicle, which is transected and then anastomosed using microsurgical techniques with the recipient artery and vein. Such a complex reconstructive operation requires special training of surgeons who must be proficient in microsurgical equipment, and also involves the use of complex, expensive equipment (an operating microscope, special instruments and ultra-thin suture material). In addition, thromboses in the area of performed microvascular anastomoses, observed in 7-18% of cases, turn a blood-supplying bone autograft into a non-blood-supplying one, which deprives it of all its advantages over the latter [1, 2].

Closest to the proposed method according to the technique of performing the operation and the features of the transplanted bone is the method of non-free autoplasty with a blood-supplying bone graft transplanted into the reconstruction area on a constant vascular pedicle — the radial artery and associated veins [1], which we took as a prototype. In this case, a bone fragment up to 10 cm long is formed along the outer surface of the distal metaepiphysis of the radial bone up to a third of its diameter on the feeding leg, including the radial artery and the associated veins of the same name. The mobilization of this vascular pedicle allows you to move the blood-supplying bone autograft with the preservation of the vessels supplying it to almost any part of the forearm and replace the bone defect of the radius or ulna [1].

The disadvantage of the described method is that only one bone fragment is isolated on the radial vascular bundle, which is formed in the region of the distal metaepiphysis of the radius. Therefore, it is suitable for replacing only one defect of the radius or ulna and cannot be used to repair defects of both bones of the forearm.

This disadvantage is deprived of the proposed method of simultaneous non-free bone autoplasty with defects and false joints of both bones of the forearm.

The technical result of the invention is the simultaneous (during one operation) replacement of two defects of both bones of the forearm by moving two blood-supplying fragments of the radial bone on a single constant supply leg, including the radial artery and the same associated veins.

The result of the invention is achieved by isolating in the region of the distal metaepiphysis of the radius and on the border of the proximal and middle thirds of two separate blood-supplying bone autografts, powered by different branches of the radial vascular bundle, as well as by moving them while maintaining the feeding vascular pedicle and fixation in the damaged areas radius and ulna bones.

The possibility of the formation of two blood-supplying bone fragments from different parts of the radius on different branches of the radial vascular bundle was proved as a result of applied topographic and anatomical studies performed on 12 non-fixed preparations of the upper extremities of corpses, including injection of arteries with black latex followed by precision preparation. Studies have shown that anatomically constant and fairly large (diameters from 0.7 to 1.5 mm) branches of the radial artery and vein approach the radius in the places of muscle attachment to it: the square pronator in the distal metaepiphysis and the round pronator in the border of the proximal and middle third of its diaphysis. Based on these data, it was concluded that it is possible in principle to form two blood-supplying bone autografts on the radial vascular bundle: from the distal metaepiphysis of the radius (up to 10 cm long) and from the diaphysis at the border of the proximal and middle third of this bone (up to 6 cm long). To eliminate the high risk of radial fractures in the areas of autologous bone autograft extraction, the width and thickness of these bone fragments should not exceed, in our opinion, one third of the corresponding radial bone parameters in these places. Subsequent modeling of the proposed operation on 6 fixed preparations of the upper extremity showed the possibility of moving both selected bone fragments to different parts of the bones of the forearm while maintaining the common feeding vascular pedicle - the radial artery and the corresponding associated veins (Fig. 1).

The lack of information in the patent and scientific literature on the possibilities of simultaneous replacement of two defects of both forearm bones by means of proprietary autoplasty with two blood-supplied bone grafts moved to the reconstruction area on a common feeding vascular bundle — the radial artery and the associated veins of the same name — indicates that the claimed technical solution meets the “novelty” criterion ".

The formation in the framework of the proposed method on the radial vascular bundle, in contrast to the prototype of two separate blood-supplying bone autografts, isolated from two different departments of the radial bone: the distal metaepiphysis and the site at the border of the proximal and middle third, allows non-free bone autoplasty to simultaneously replace two defects of both bones of the forearm. The proposed method differs from two analogues by the method of bone autograft transplantation (non-free plastic surgery is used in contrast to free bone plastic). Thus, the proposed technical solution meets the criterion of "significant difference".

Indications for clinical use of the proposed method are the presence of two defects or false joints of the radius and ulna.

The drawings show:

Figure 1. The result of isolation on a fixed preparation of the left upper limb of two bone grafts on the proximal vascular pedicle, including the radial vascular bundle: 1 - bone graft from the distal radial metaepiphysis; 2- bone graft from the radial diaphysis; 3-beam vascular bundle.

Figure 2. Scheme of the right forearm with the designation of the radius and ulna, the sites of damage and the main arterial trunks: 1 - the place of formation of the bone graft from the distal radial metaepiphysis; 2 - the place of formation of the bone graft from the radial diaphysis; 3 - beam vascular bundle; 4 - the site of damage to the ulna; 5 - the site of damage to the radial bone.

Figure 3. Scheme of the right forearm with the designation of the radius and ulna, places of damage, displaced blood-supplying bone autografts and main arterial trunks: 1 - bone autograft, moved to the area of damage to the radius; 2 - a bone autograft transferred to the ulnar lesion area; 3 - beam vascular bundle; 4 - the site of damage to the ulna; 5 - the site of damage to the radial bone.

Figure 4. The stage of isolation during surgery on the right forearm of patient A. of two blood-supplied bone autografts on a single vascular pedicle, including the radial vascular bundle: 1 - bone autograft from the distal radial metaepiphysis, 2 - bone autograft from the radial diaphysis; 3 - beam vascular bundle.

Figure 5. The result of the isolation during the operation of patient A. of two blood-supplied bone autografts on a single vascular pedicle, including the radial vascular bundle: 1 - bone autograft from the distal radial metaepiphysis, 2 - bone autograft from the radial diaphysis; 3 - beam vascular bundle.

Figure 6. The result of transosseous osteosynthesis of the forearm bones and the movement of patient A. two blood-supplying bone autografts on a single feeding vascular leg, including the radial vascular bundle: 1 - bone autograft from the distal radial metaepiphysis fixed at the site of damage to the radial bone.

Figure 7. Consolidation of fragments of both bones of the forearm in patient A. 6 months after surgery by the proposed method: 1 - a bone autograft from a distal radius radial metaepiphysis at the site of a fused fracture of the radius; 2 - bone autograft from the radius of the radial bone at the site of the fused fracture of the ulna.

The method is as follows. First, an incision is made in the skin, subcutaneous fatty tissue and the forearm's own fascia along the projection line of the radial artery: from the middle of the ulnar fossa to a point located 1.5 cm inward from the styloid process of the radius. Then the tendon of the radial flexor of the wrist is displaced medially, and the tendon of the brachioradialis muscle is laterally. A radial vascular bundle is found and carefully secreted at the level of the wrist joint gap. Then, one or several small branches of the radial artery and associated veins (with a diameter of 0.5 to 1 mm) going to the square pronator and further to the periosteum of the radius along the outer edge of its metaepiphysis are identified in the wound. These vascular branches are carefully mobilized in the direction from the radial vascular bundle to the radius, together with the adjacent fibers of the square pronator. Then, the radius bone osteotomy is performed with a chisel and a blood-supplying bone fragment of the required size is isolated from the lateral edge of its metaepiphysis (Fig. 2). The length of this blood supply bone graft can vary from 4 to 10 cm, the width should be at least 1 cm, and the thickness should not exceed one third of the radius of the radius in this place. An isolated cortical-spongy fragment of the radius must necessarily maintain vascular connections with the radial vascular bundle.

At the next stage of the operation, the radial vascular bundle distal to the selected bone fragment is twice ligated and crossed. Next, the radial artery and associated veins are mobilized in the proximal direction until they intersect with the distal edge of the circular pronator, coagulating and crossing all the lateral vascular branches. Then, branches of the radial artery and associated veins are found in the wound, heading at this level to the periosteum of the radial bone diaphysis at the border of the proximal and middle third. These branches secrete from the radial artery to the radial bone along with the fibers of the round pronator. Next, the radius bone osteotomy is performed with a chisel and a second blood-supplying bone fragment is isolated from its diaphysis (Fig. 2). The length of the second bone graft can vary from 3 to 6 cm, the width should be less than 0.8 cm, and the thickness should not exceed one third of the thickness of the radius of the radial bone.

The next stage continues the mobilization of the radial vascular bundle in the proximal direction even 3-5 cm above the upper edge of the second bone graft, coagulating and crossing the lateral branches of the radial artery and associated veins. Next, two blood-supplying bone autografts formed on a single feeding vascular pedicle — the radial vascular bundle — are moved proximally and placed in areas of existing defects or false joints of the radius and ulna (Fig. 3). The transplanted blood supply bone fragments are fixed to the damaged bones with knitting needles with emphasis. An external fixation device is placed on the forearm. An operational wound is sutured in layers.

Clinical example. Patient A., and / b No. 6502, was admitted for treatment at FGU "RNIITO named after RR Vredena Rosmedtekhnologii "May 24, 2007 with a diagnosis of a defect of the ulna in the upper third and the pseudarthrosis in the middle third of the radius of the right forearm. Injury - a closed fracture of the upper third of the ulnar bone of the right forearm was received on July 12, 2005 as a result of a traffic accident. After three months of gypsum immobilization, nonunion of bone fragments was revealed. Refusing further treatment, the patient began to work, but again sought medical help after two years. On January 24, 2007, he underwent an operation: a shortening resection of the radius of the right forearm, transosseous osteosynthesis of both bones of the forearm with an external fixation device. However, fusion of the forearm bones was not achieved, and repeated surgical treatment was required.

The operation of the proposed method was performed on June 7, 2007. During the intervention, an end resection of the bone fragments of the radial and ulnar bones was performed, as well as the isolation of two blood-supplied bone autografts on a common proximal vascular pedicle - the radial vascular bundle (Fig. 4). The sizes of the distal and proximal bone autografts were: 7 × 1.5 × 1.5 cm and 4.5 × 1 × 1 cm, respectively (Fig. 5). Further, blood-supplied bone autografts were moved with preservation of the supply vessels to the sites of defects of the radius and ulna. Fragments of these bones were juxtaposed, and on the side were blocked by blood-supplying bone autografts, which were fixed to them with needles with emphasis. Then, a combined transosseous osteosynthesis of both forearm bones was performed using an external fixation device (Fig. 6). The postoperative period was uneventful, the patient was discharged 9 days after surgery.

During the control examination on November 30, 2007, the consolidation of bone fragments of both bones of the forearm (Fig. 7) and the almost complete restoration of the function of the right upper limb were observed. The external fixation device was dismantled.

Bibliography

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2. Golovchak B.Ya. Clinical and morphological characteristics of free vascularized tubular bone grafts: Abstract ... cand. honey. sciences. - M., 1993 .-- 23 p.

3. Golubev V.G. Free transplantation of bone autografts on a vascular pedicle for defects in tubular bones: Abstract ... cand. honey. sciences. - M., 1985. - 16 p.

4. Zatsepin S.T. Preserved surgery for bone tumors. / S.T. Zatsepin. - M .: Medicine, 1984. - 102 p.

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Claims (1)

The method of simultaneous non-free bone autoplasty with defects and false joints of both forearm bones, characterized in that two blood-supplying bone autografts are isolated from the radial bone - from the distal metaepiphysis and from the site at the border of the proximal and middle third of the radial bone - on a single proximal vascular leg - beam the vascular bundle, bone autografts are moved while maintaining the supply vessels and fix them in areas of damage to the radius and ulna.

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