RU2393796C1 - Method of operative treatment of first toe valgus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics and is aimed at operative treatment of first toe valgus. Osteochondroma is resected. Performed are osteotomy of distal part of instep bone with cutting out of bone wedge with base inwards, transversal osteotomy in area of first instep bone base with preservation of external cortical lamella. Bone wedge is introduced into rift. Zones of osteotomy are fixed by means of device of external fixation containing three rods and one console wire, which are introduced outside of metatarsophalangeal articulation, without injuring articulation surface. One rod with 4 mm diametre is passed into the base of first toe main phalanx after puncturing skin with scalpel and preliminary boring. The second rod with 4 mm diametre is passed in the middle third of instep bone diaphysis too. The third rod with 4 mm diametre is passed into cuneiform bone. Additionally console wire is passed into instep bone head. Rods are fixed by means of rod-fixers, the wire being fixed by means of wire-fixer to external support of lamellar attachment from Ilizarov G.A apparatus.

EFFECT: method allows to fix in a stable way osteotomated bone fragments, prevent development of contractures and arthrosis of first metatarsophalangeal articulation.

1 ex, 6 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and is directed to surgical treatment of hallux valgus deformity of the 1st toe.

A known method of surgical treatment of valgus deformity of the first toe with excision of a wedge from the head of the 1st metatarsal bone with its movement to the osteotomy of the base of the 1st metatarsal bone (Logroshino operation, "Traumatology and Orthopedics" edited by G.S. Yumashev, Moscow, "Medicine", 190, p.565) with transarticular fixation with a spoke and immobilization in a plaster cast.

Significant disadvantages of the above method of surgical treatment are the following:

1) there is no stable fixation of osteotomized bone fragments;

2) transarticular insertion of the spoke leads to damage to the articular surfaces and the development of further contracture and arthrosis of the 1st metatarsophalangeal joint;

3) long-term immobilization with plaster casts is required, which contributes to the development of joint contractures, limits the mobility of patients;

4) requires long physiological and functional rehabilitation.

There is also a method of eliminating hallux valgus deformity of the first toe by removing bone-cartilaginous growths along the medial edge of the head of the 1st metatarsal bone, resection of 1/3 of the base of the proximal phalanx of the 1st finger (Schede-Brandes operation), subperitoneal transverse osteotomy of the base of the 1st metatarsal bone, implantation between fragments at the site of an osteotomy of a bone wedge from the resected base of the proximal phalanx of the thumb and transarticular fixation with a spoke (Cherkes-Zade DI, Kamenev Yu.F. “Foot surgery”, M. Medits Ina. - 1995 .-- 219-222).

The method has the following disadvantages:

1) intraarticular intervention;

2) osteosynthesis with a knitting needle is unstable and requires external immobilization with a plaster cast for a period of 4-6 weeks, which, in turn, leads to the development of contractures in the joints of the foot and ankle joint, sharply limits the patient's support ability and necessitates the use of external supports (crutches );

3) transarticular introduction of a spoke leads to damage to the articular surfaces and the development of further contracture and arthrosis of the 1st metatarsophalangeal joint;

4) prolonged plaster immobilization, limitation of support lead to a long physiological and functional rehabilitation of the patient.

Closest to the proposed method is the "Method of surgical rehabilitation of patients with" hallux valgus "(Beidik OV, Levchenko KK, Antonova TN Patent No. 2259174 C1, A61B 17/56). The method consists in the following: an exostosis is resected, a wedge-shaped resection of the distal 1st metatarsal bone and a wedge are inserted into the bone splint after its osteotomy in the proximal part, the foot bones are fixed with cantilever knitting needles, which are attached to the external supports of G. Ilizarov’s apparatus Fixation is carried out by introducing cantilever knitting needles from the back of the foot, perpendicular to the long axis of the 1st toe and metatarsal bone, in the direction from top to bottom outside-inside and outside-outward, at an angle of 90 degrees to each other, into the proximal phalanx of the thumb , 1st metatarsal bone at the level of the head, middle third of the diaphysis and the base, which are fixed with washers with a slot in the external fixation device, consisting of multi-hole strips from the apparatus of Ilizarov G.A. Planks are interconnected by threaded ties.

However, the method has the following disadvantages:

1) for a sufficiently stable fixation of the elements of the 1st metatarsal bone, 4 pairs of cantilever spokes are necessary, which is traumatic;

2) the volume and dimensions of the external fixation device create inconvenience for the period of fixation when walking, wearing shoes;

3) the condition for stable fixation of fragments of the 1st metatarsal bone is a strict perpendicular direction of the cantilever spokes of the longitudinal axis of the 1st metatarsal bone and their mutually perpendicular conduction at an angle of 90 degrees, which complicates and increases the operation time.

This method of surgical treatment of hallux valgus of the first toe is taken as a prototype, the disadvantages of which are completely eliminated by our treatment method.

The purpose and objective of our proposed method is to eliminate the above disadvantages, it provides:

- achieving stable fixation of fragments of the 1st metatarsal bone for the entire period of fusion by holding 3 rods and 1 spoke,

- the compactness of the external fixation device, which allows walking in the first days after the operation, wearing selected shoes, without causing inconvenience,

- low injuries, simplicity and reduction of the operation time, due to the use of 3 rods and 1 knitting needles and without the need to observe strictly perpendicular introduction of knitting needles.

To achieve a medical and technical result, we do the following: in the method of surgical treatment of hallux valgus of the first toe to achieve stable fixation of fragments of the 1st metatarsal bone for the entire period of fusion, low trauma and eliminate inconvenience when walking, in contrast to the prototype, we use an external fixation device consisting of 3 rods held at the base of the main phalanx of the 1st toe, in the diaphysis of the metatarsal bone, in the sphenoid bone, and 1 cantilever spoke held in the metatarsal head bone, fixed on a multi-hole plate.

The inventive method is illustrated by drawings.

The method is as follows. Under spinal anesthesia, an arcuate incision is made along the inner lateral surface of the foot from the level of the base of the main phalanx 1-1.5 cm above the level of the planned osteotomy of the metatarsal head. Remove the mucous bursa over the area of bone-cartilaginous exostosis of the head. Retreating 3-5 mm from the upper edge of the articular surface of the head of the metatarsal bone, a bone wedge is cut in the transverse direction by a pendulum saw in the transverse direction with the base of the inside, thickness depending on the degree of deformation (Fig. 1). A transverse osteotomy is performed in the base region of the 1st metatarsal bone, preserving the external cortical plate, the osteotomy zone is expanded and the prepared bone wedge is inserted into it. Bringing the head with the proximal fragment of the bone (figure 2). Next, the bone-cartilaginous exostosis of the head is cut off under the base, the sawdust is ground with a small rasp (Fig. 3). To ensure stable fixation of bone fragments and rotational stability, an external fixation device is installed on three rods and one cantilever spoke. One rod with a diameter of 4 mm, after puncture with a scalpel of a skin measuring 0.3 cm in size and preliminary reaming, is carried out at the base of the main phalanx of the 1st toe, a second rod with a diameter of 4 mm is also carried out in the s / s diaphysis of the metatarsal bone, and a third rod with a diameter of 4 mm into the sphenoid bone without observing a strictly perpendicular direction to the long axis of the metatarsal bone. Additionally, a cantilever spoke is inserted into the head of the metatarsal bone. The rods are fixed with the help of rod fixators, and the spoke with the help of a spoke fixator - to the external support of the plate prefix from the apparatus of Ilizarov G.A. The length of the plate prefix from the apparatus Ilizarova G.A. determined by the distance between the 1st and 3rd rods for maximum compactness of the external fixation device (figure 4). The wound is sutured in layers.

Practical Application Example:

Patient EI Nesvizhsky, and / b No. 7929, 68 years old, was admitted to Design Bureau No. 1 of the RF UDP with a diagnosis of hallux valgus deformity of 1 toes of both feet of the 3rd degree. In the preoperative period, an X-ray and computed tomography study of the feet was carried out with determination of the angles and degree of deformation (Fig. 5). Operations were performed on both feet according to the method we proposed: osteotomy of the distal metatarsal bone with a bone cut out with the base of the inside, transverse osteotomy in the region of the base of the 1st metatarsal bone, preserving the external cortical plate and introducing the prepared bone wedge into the cleavage, the head is brought closer to the proximal fragment bones, osteo-cartilaginous exostosis of the head is sawn under the base, sawdust polished with a small rasp. To ensure stable fixation of bone fragments and rotational stability, an external fixation device was installed on three rods and one cantilever spoke. One rod with a diameter of 4 mm, after piercing with a scalpel of a skin measuring 0.3 cm and pre-reaming, is directed to the base of the main phalanx of the 1st toe, the second rod with a diameter of 4 mm, after piercing with a scalpel of skin with a size of 0.3 cm and preliminary reaming, is directed in the s / s diaphysis of the metatarsal bone, the third rod with a diameter of 4 mm, after piercing with a scalpel of the skin with a size of 0.3 cm and preliminary reaming, is directed to the sphenoid bone. Additionally, a cantilever spoke was inserted into the head of the metatarsal bone. Holding rods and knitting needles does not require adherence to the strictly perpendicular direction of the long axis of the 1st metatarsal bone. The rods are fixed with the help of rod fixators, and the spoke with the help of a spoke fixator - to the external support of the plate prefix from the apparatus of Ilizarov G.A. (Fig.6). Walking is allowed on the next day after the operation with the help of "walkers", after 3 days walking without additional support. When walking, external fixation devices do not cause inconvenience, allow you to wear selected shoes. Postoperative wounds healed by first intention, the sutures were removed on the 14th day. External fixation devices were removed on the 45th day after the operation. During the observation and to date, there are no complaints, the movements in the 1st metatarsophalangeal joint in full, are painless. The patient feels well.

From 1999 to 2008 we tracked the results of treatment of 46 patients operated on by the specified method. Eliminated valgus deformity of 1 toes of both feet, stable fixation of fragments of the 1st metatarsal bone for the entire period of fusion without compromising the integrity and mobility of the metatarsophalangeal joint, allowing early movement in the joint, walking in the first days after surgery without additional support and additional immobilization, the compactness of the external fixation device and the convenience when walking with wearing selected shoes.

All patients noted the advantages of the proposed method of surgical treatment:

1) the method allows to operate both feet with less trauma and provides a condition for the load on the operated feet from the first days after the operation, without using external supports (crutches, “walkers”) when walking and special orthopedic shoes;

2) stably fix fragments of the 1st metatarsal bone for the entire period of fusion, without violating the integrity and mobility of the metatarsophalangeal joint, allowing early movement in the joint, as the prevention of contracture and arthrosis of the 1st metatarsophalangeal joint;

3) compactness and location on the foot of the external fixation device does not cause discomfort for patients when walking, allows you to wear selected shoes

The list of drawings for the description of the invention

Figure 1 - marked wedge-shaped osteotomy under the head of the 1st metatarsal bone and transverse osteotomy in the base region of the 1st metatarsal bone.

Figure 2 - zone of osteotomy at the base of the 1st metatarsal bone with the implementation of the prepared bone wedge and the approach of the head with the proximal fragment of the bone.

Figure 3 - removal of bone-cartilage exostosis of the head under the base.

Figure 4 - installation of external fixation devices on three rods and one cantilever spoke, fixation with the help of rod clamps and a spoke fixator to the external support of the plate prefix from the apparatus of Ilizarov G.A.

Figure 5 - x-ray examination of the feet with the determination of angles and degree of deformation.

6 - radiographs of the feet, operated by the presented method.

Claims (1)

A method for surgical treatment of valgus deformity of the 1st toe, which consists in resection of the bone-cartilaginous exostosis, osteotomy of the distal metatarsal bone with the implementation of a bone wedge with the base of the inside, transverse osteotomy in the base of the 1st metatarsal bone, preserving the external cortical plate and introducing into the cleavage harvested bone wedge, characterized in that the zones of osteotomy are fixed using an external fixation device on three rods and one cantilever spoke, which is inserted outside the 1st metatarsal of the joint without damaging the articular surfaces: one rod with a diameter of 4 mm, after piercing with a scalpel of a skin measuring 0.3 cm and pre-reaming, is carried out at the base of the main phalanx of the 1st toe, the second rod with a diameter of 4 mm is also carried out in the middle third of the diaphysis of the metatarsal bone, the third rod with a diameter of 4 mm, is also carried out in the sphenoid bone, in addition to the head of the metatarsal bone a cantilever needle is carried out, without the need to observe a strictly perpendicular direction with their axis length of the 1st metatarsal bone and the rods are fixed with the help of rod fixators, and the spoke with the help of a spoke fixator to the external support of the plate prefix from the apparatus Ilizarova G.A.

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