RU2405487C1 - Method of surgical treatment of comminuted fracture of proximal part of humerus, clamp and implant for its realisation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions relates to field of medicine, in particular to traumatology and orthopedics and can be applied in treatment of patients with comminuted fractures of proximal part of humerus. After removal of small bone fragments into intramedular canal hammered is cylindrical implant from porous titanium nickelide with internal through central canal, semi-cylindrical longitudinal slot on lateral surface and through transversal canal in proximal part of cylinder. Implant is installed in such way that longitudinal slot is located parallel to lateral surface of humerus, and lower opening of transversal canal on anterior surface of implant is located laterally. Head of humerus is put onto protruding end of cylindrical implant. Bone fragments are laid with recovery of form of proximal segment of humerus. Opposite central canal of cylindrical implant and over its semi-cylindrical longitudinal slot in shoulder head, at the level of greater tubercle closer to anatomical neck formed are canals for intramedular legs of first clamp. After that first clamp from alloy with thermomechanical memory is used. Loop-like back of first clamp is made from three differently directed loops, extreme loops are directed with loop down, central one - with loop up. Extreme loops are bent inside clamp in direction to legs, arches are oriented in direction of intramedular legs to each other, intramedular legs diverge. Clamp is cooled. Loops of first clamp are stretched for 10-15 mm and drawn away from legs. One of legs is installed through central canal of cylindrical implant into diaphysis of humerus, second intramedular leg is installed into longitudinal slot on lateral surface of cylindrical implant. Clamp loops are placed above greater and lesser tubercles, enclosing them on perimetre. Holes for upper legs of second and third clamps with S-shaped back from alloy with thermomechanical memory are formed above loops of first clamp, directed downwards, one hole being placed at the level of transversal canal of implant. Holes for lower legs of second and third clamps are drilled in region of distal fragment of humerus. Clamps with S-shaped back are cooled. Bends of back are straightened to increase linear dimension on 10-15 mm. Legs of S-shaped clamps are installed into prepared holes, upper leg of one of S-shaped clamps being introduced into head of humerus through transversal canal of cylindrical implant. Clamp contains loop-like back, passing through arches into intramedular legs. Arches are bent in lateral plane, lying perpendicular to plane of intramedular legs, loop-like back being made from three differently directed loops, extreme loops are directed with loop downwards, central one - with loop upwards. Extreme loops are bent inside clamp in direction towards legs, arches bent in lateral plane are oriented in direction of intramedular legs to each other at 50° angle. Intramedular legs diverge at 15° angle in plane. Clamp is made from alloy with thermomechanical memory of form. Implant from porous titanium nickelide is made in form of cylinder and has internal through central canal, semi-cylindrical longitudinal slot on lateral surface and through transversal canal, located between internal through central canal and semi-cylindrical longitudinal slot, at distance from implant axis equal to radius of internal through central canal.

EFFECT: inventions ensure increase of strength of stabilisation of bone fragments of humerus proximal segment in anatomically correct position, achievement of transversal inter-fragmental compression of bone fragments of greater and lesser tubercles of metadiaphyseal zone of humerus, performing compression in sagittal and frontal planes, elimination of mobility of small splinters in proximal part of humerus, compensation of bone tissue deficiency and reconstruction of destroyed proximal segment of humerus.

1 ex, 3 cl, 13 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of patients with comminuted fractures of the proximal humerus.

As a rule, comminuted fractures of the proximal humerus are observed in patients with concomitant osteoporosis, accompanied by impression, bone deficiency. When performing osteosynthesis, the fixing elements of the structures are poorly retained in the osteoporotic head of the humerus. There is a high probability of structural migration, destabilization of fixation, up to the secondary displacement of bone fragments with the formation of a false joint in the vicious position of fragments. In addition, osteosynthesis must be supplemented with bone grafting to eliminate bone deficiency, which significantly increases the injury rate of the operation.

A known method for surgical treatment of the pseudoarthrosis of the proximal humerus according to patent RU No. 2233638, IPC АВВ 17/56, 08/10/2004. An autograft from the fibula is telescopically inserted into the head and metaphysis of the humerus, the shoulder head, the autograft is fixed with two braces with memory effect forms. To the diaphysis of the humerus, the staples are positioned in diametrically opposite directions.

The disadvantage of the proposed method of treatment is the need to perform surgery to collect an autograft from the fibula, which increases the injury rate of the intervention. The strength of the fibula is significantly weakened and after surgery, prolonged immobilization of the lower limb is necessary until the fibula is restored. Osteosynthesis with two tightening brackets with transosseous legs does not provide longitudinal splinting of the humerus. There is a tendency to shift the short proximal segment.

A device for osteosynthesis of periarticular fractures is made of material with a shape memory effect in the form of a two-jaw hairpin with curved branches and a half-head mounted at an angle of 40 ° with respect to branches according to copyright certificate No. 1136804, IPC АВВ 17/56, БИ No. January 4, 1930.

A device for osteosynthesis in the form of a hairpin can be used to fix a large tubercle of the humerus when it is detached, or to fix fragments during fractures at the level of the anatomical neck of the humerus.

The disadvantage of this device is the impossibility of reliable fixation of fragments during comminuted extracuspid fractures, the lack of interfragmental compression between bone fragments, which significantly slows down the process of bone tissue regeneration.

A device for compression osteosynthesis according to the copyright certificate No. 1057026, IPC АВВ 17/18, BI No. 44, 11/30/1983, containing a bracket made of material with a shape memory effect, has an intramedullary leg and bone corrugated elements, at the ends of which there is a leg for installation into the bone.

A device for compression osteosynthesis can be used to fix fragments in fractures of the surgical neck of the humerus. Provides longitudinal splinting of fragments and interfragmental compression of the proximal and distal bone fragments.

The disadvantage of this device is the lack of elements for cord wrapping with a comminuted nature of the damage, the mismatch of the shape and contours of the osseous corrugated elements with the topographic and anatomical features of the proximal segment of the humerus. The conditions for the introduction of the intramedullary pedicle through the large tubercle of the humerus excludes the introduction of staples with a comminuted nature of the damage.

It is known to use porous titanium nickelide as an implant material replacing a bone defect. A.B.Kazantsev, I.R. Kuzina, S.A. Cherkasova. Methods of surgical treatment of impression fractures of the shoulder. Actual issues of implantation and osteosynthesis. Novokuznetsk. - St. Petersburg, 2001, p. 15-16. Depending on the characteristics of the defect, the method varies by methods of restoring the normal surface of the head and filling the resulting void with an implant. After osteotomy of the defect, the cavity formed is filled with a porous nickelide titanium implant, which is simulated as much as possible in defect shape. On top of the defect is covered with a fibrous membrane of the type "house roof".

The disadvantages of this method are the impossibility of lifting osteotomy with a large size of the impression defect, the difficulty of modeling anatomically adequate implants, the low reliability of the restored joint due to grinding of the bone “flaps” on the roughness of the implant and subsequent prolapse of the implant.

The closest in technical essence to the claimed method is a method for surgical treatment of fractures of the surgical neck of the humerus and the clamp used for this. Guide to osteosynthesis with fixators with thermomechanical shape memory. Part I. / Edited by V.V. Kotenko, Russian Research Institute. Novokuznetsk State Institute for Advanced Medical Studies. Siberian Research Center for Disaster Medicine, Novokuznetsk, 1996, p. 33-38.

The method includes osteosynthesis of the proximal humerus.

The implementation technique is as follows: drilling two holes in the region of the large tubercle of the humerus at a distance of 10-15 mm from each other, respectively, the width of the double-jawed spokes, through the large tubercle into the drilled holes in the direction of the intramedullary canal of the distal fragment of the humerus introduce the branches of the loop-shaped knitting needle. Then the bone fragments are compared and the two-jawed spoke is gently pounded into the bone until bent. In the region of a large tubercle above the loop, a hole is drilled under the leg of a bracket made of a material with a shape memory effect and another hole on the diaphysis of the humerus. The distance between the proximal and distal openings should be 10-20 mm longer than the length of the back of the bracket designed for compression osteosynthesis. Next, a bracket of titanium nickelide in liquid nitrogen is cooled. Straighten the curved back and legs of the bracket. Insert the staple leg into the proximal periarticular fragment through the loop of the double-jawed needle, and the second leg into the hole made on the outer surface of the distal fragment of the humerus. When the staples are heated, shape restoration and compression of the bone fragments of the humerus occur.

The disadvantages of the method are:

- mismatch of the compression area of the joined fragments of the area of their fracture, which is fraught with a secondary displacement of bone fragments;

- insufficient axial fixation of fragments in the fracture region of the surgical neck of the humerus due to the small thickness of the spokes;

- insufficient transverse interfragmental compression of bone fragments;

- the impossibility of filling the bone deficit of the destroyed proximal segment of the humerus.

The objective of the invention is to increase the effectiveness of treatment by restoring the anatomical shape of the proximal segment of the humerus by plastic surgery of the bone defect with an implant made of porous titanium nickelide, increasing the efficiency of osteosynthesis due to the uniform distribution of compression forces along the fracture plane, along the length and width with pressing the bone fragments to the implant, increasing the stability of stabilization of bone fragments of the proximal segment of the humerus in the anatomically correct position.

The task is achieved by the method of surgical treatment of comminuted fracture of the proximal humerus, including the installation of a cylindrical implant made of porous titanium nickelide and osteosynthesis with alloy brackets with thermomechanical shape memory.

After removal of small bone fragments, a cylindrical implant of porous titanium nickelide with an internal through central channel, a semi-cylindrical longitudinal groove on the lateral surface and a through transverse channel in the proximal part of the cylinder is hammered into the intramedullary canal. In this case, the implant is installed so that the longitudinal groove is parallel to the lateral surface of the humerus, and the lower opening of the transverse channel on the front surface of the implant is laterally. On the protruding end of the cylindrical implant, the head of the humerus is inserted, bone fragments are placed with the restoration of the shape of the proximal segment of the humerus. Opposite the through central channel of the cylindrical implant and above its semi-cylindrical longitudinal groove in the shoulder head, at the level of a large tubercle closer to the anatomical neck, channels are formed under the intramedullary legs of the first bracket. Then, the first bracket from the alloy with thermomechanical shape memory is used, with the loop-shaped back of the first bracket made of three differently directed loops, the extreme loops directed downward and the central loop upward, extreme loops bent inward of the bracket towards the legs, arcs oriented in the direction of the intramedullary legs towards each other, and the intramedullary legs diverge. The bracket is cooled, the loops of the first bracket are stretched by 10-15 mm and removed from the legs, one of the legs is installed through the central channel of the cylindrical implant into the diaphysis of the humerus, the second intramedullary leg is installed in a half-cylindrical longitudinal groove on the side surface of the cylindrical implant. The staple loops are placed above the large and small tubercles, covering them around the perimeter. Holes are formed for the upper legs of the second and third brackets with an S-shaped backrest made of an alloy with thermomechanical shape memory above the loops of the first bracket, directed downward, with one hole being placed at the level of the transverse channel of the implant. Drill holes for the lower legs of the second and third staples in the region of the distal fragment of the humerus. The staples with an S-shaped back are cooled, the bends of the back are straightened to increase the linear size by 10-15 mm. The legs of the S-shaped brackets are installed in the prepared holes, the upper leg of one of the S-shaped brackets being inserted into the head of the humerus through the through transverse channel of the cylindrical implant. When heated and shaped, longitudinal interfragmental compression of the proximal and distal fragments is achieved, and rotational displacement along the length and width of the fracture plane is prevented.

The task is also achieved by the fact that the bracket containing a loop-shaped back, passing through the arches to the intramedullary legs, has arcs curved in the lateral plane lying perpendicular to the plane of the intramedullary legs. The loop-shaped back is made of three oppositely directed loops, the extreme loops are directed the loop down, and the central loop is looped up. The extreme loops are bent inside the bracket towards the legs. Arcs curved in the lateral plane are oriented in the direction of the intramedullary legs towards each other at an angle of 50 °. The intramedullary legs diverge at an angle of 15 ° in the plane. The bracket is made of an alloy with thermomechanical shape memory.

The task is also achieved by the fact that they use an implant made of porous titanium nickelide, made in the form of a cylinder. The implant has an internal through central channel, a semi-cylindrical longitudinal groove on the side surface and a through transverse channel located between the internal through central channel and the semi-cylindrical longitudinal groove at a distance from the implant axis equal to the radius of the internal through central channel.

The proposed method allows to achieve transverse interfragmental compression of bone fragments of the large and small tubercles, the metadiaphyseal zone of the humerus, due to the execution of the osseous element of the bracket in the form of omega-shaped loops, and compression in the sagittal and frontal planes is provided.

The presence of divergent intramedullary legs of the bracket and the osseous element provide longitudinal and twisting splinting of the damaged segment, the mobility of short proximal fragments is excluded.

The use of a cylindrical implant makes it possible to compensate for the deficiency of bone tissue and serves as an axial rod when reconstructing the destroyed proximal segment of the humerus.

The installation of two compression brackets with S-shaped backs provides longitudinal interfragmental compression of the proximal and distal fragments, rotational displacements along the length and width of the fracture plane are prevented, and large and small tubercles of the osseous back are additionally pressed.

The proposed method and device are presented in Fig.1-13a, b, c.

Figure 1 - bracket, axonometric projection.

Figure 2 is a side view of the bracket.

Figure 3 is a front view of the bracket.

Figure 4 - bracket after deformation in a refrigerated state before installation, axonometric projection.

Figure 5 - bracket, top view.

6 - shows a method of implant placement and osteosynthesis with braces, side view.

7 - shows a method of implant placement and osteosynthesis with braces, front view.

Fig. 8 shows a method of implant placement and osteosynthesis with brackets, axonometric projection.

Figure 9 - implant made of porous titanium nickelide, axonometric projection.

Figure 10 - implant, top view.

11 is an implant, front view.

Fig - implant, side view from the side of the groove.

Figa - radiograph of the proximal segment of the humerus before surgery.

Figb - x-ray three weeks after surgery.

Figv - radiograph 1 year after surgery.

The bracket contains a loop-shaped back, passing through the arcs 1 to the intramedullary legs 2, the arcs 1 are bent in the lateral plane, Figure 2, lying perpendicular to the plane of the intramedullary legs 2, Figure 1. The loop-shaped back is made of three oppositely directed loops, the extreme loops 3 are directed loop down, and the central 4 is looped up. The extreme loops 3 are bent inward of the bracket towards the legs 2, FIG. 3. Arcs 1 are oriented in the direction of the intramedullary legs 2 towards each other, Figure 5. The intramedullary legs 2 diverge, Figure 1. The bracket is made of an alloy with thermomechanical shape memory.

Porous titanium nickelide implant in the form of a cylinder 5, Fig.9. The implant 5 has an internal through central channel 6, a semi-cylindrical longitudinal groove 7 on the side surface and a through transverse channel 8 located between the internal through central channel 6 and the half-cylindrical longitudinal groove 7, at a distance from the implant axis equal to the radius of the internal through central channel, FIG. 9-12. The through transverse channel 8 is directed from the lower hole 9 on the front surface of the cylinder to the upper hole 10 on the rear surface of the cylinder, Fig.9, 12.

The method is as follows.

Depending on the degree of destruction of the soft tissue and bone structures of the shoulder joint, anterior deltoidepectoral or transacromial surgical approach is performed. The proximal segment of the humerus is exposed. Small bone fragments free-lying in soft tissues are removed. A cylindrical implant 5 of porous titanium nickelide at 2/3 of its height is hammered into the intramedullary canal of the distal fragment. The implant 5 serves as an axial rod in the restoration of the destroyed proximal segment of the humerus. Install the implant 5 so that the longitudinal groove 7 is parallel to the lateral surface of the humerus, and the lower opening 9 of the transverse channel 8 on the front surface of the implant 5 is laterally. On the protruding end of the cylindrical implant 5, the head of the humerus is inserted. Lay the bone fragments of the large and small tubercles and bone fragments at the level of the surgical neck with the restoration of the anatomically correct shape of the proximal segment of the humerus, Fig.6-8.

For the purpose of twisting and longitudinal splinting of bone fragments, osteosynthesis is performed using the first bracket. Opposite the through central channel 6 of the cylindrical implant 5 and above its semi-cylindrical longitudinal groove 7 in the shoulder head at the level of a large tubercle closer to the anatomical neck, channels are formed under the intramedullary legs of the first bracket made of an alloy with thermomechanical shape memory. The first bracket is cooled to -10 ° C, loops 3 and 4 are stretched so that the lateral size of the stitch back loops increases by 10-15 mm, and is removed from the legs 2, for ease of installation of the first bracket, Fig. 4. The design is transferred to the wound. Osteosynthesis is performed with the first bracket with a back in the form of a loop passing through the lateral arches 1 into the intramedullary legs 2. One of the legs 2 is installed through the through central channel 6 of the cylindrical implant 5 into the diaphysis of the humerus. The second intramedullary leg 2 of the device is installed in a semi-cylindrical longitudinal groove 7 on the lateral surface of the cylindrical implant 5, Fig. 8. Immerse the legs 2 of the first bracket in the bone until the lateral arches 1 are bent. Loops 3 and 4 are placed above the large and small tubercles, covering them around the perimeter. When heating and form restoration of the first bracket, loops 3 and 4 press fragments of fragments of the large and small tubercles of the humerus to the cylindrical implant 5, preventing their displacement along the width of the humerus. Compression is performed in the sagittal and frontal planes. The diverging intramedullary legs 2 provide longitudinal splinting, and the osseous portion of the curved loops provides a twisted splinting of the damaged segment, which excludes the mobility of the short proximal fragment.

For the purpose of longitudinal compression of the proximal and distal fragments, two brackets are installed with S-shaped backs made of an alloy with a thermomechanical shape memory.

In the region of the large tubercle above the first staples loops, directed downward, and in the region of the distal fragment of the humerus, holes are drilled under the legs of the staple 11. The bracket 11 is cooled, the S-shaped back is straightened, and the legs are straightened and inserted into the prepared holes, fixing the back with one leg staples in the form of a loop 3, and the second leg is immersed in the hole in the diaphysis of the humerus. One hole 9 is located at the level of the through transverse channel 8 of the implant. The upper leg of the bracket 11 of S-shaped staples is inserted into the head of the humerus through the transverse channel 8 through the lower hole 9 of the cylindrical implant 5, Fig. 8.

Install the third bracket 12 with an S-shaped backrest made of an alloy with thermomechanical shape memory.

A hole is drilled under the upper leg of the third bracket 12 above the second loop 3, directed down the back of the first bracket. A hole is drilled under the lower leg of the third bracket 12 in the region of the distal fragment of the humerus, Figs. 7, 8. The third bracket 12 with the S-shaped back is cooled to -10 ° C, the bends of the back are straightened to increase the linear size by 10-15 mm, set legs of S-brackets in prepared holes. When heated and shaped, longitudinal interfragmental compression of the proximal and distal fragments is achieved, and rotational displacement along the length and width of the fracture plane is prevented. Soft tissue of the shoulder joint is restored. The wound is sutured. The damaged arm is fixed with a scarf dressing with a roller in the axillary region.

Example.

Patient T., 69 years old, was admitted to the trauma unit after falling on her arm. Diagnosis: impression fracture of the proximal segment of the humerus with separation of the large and small tubercles, displacement of fragments, osteoporosis of the II degree, Fig.13a.

On the day of admission, an open reduction was performed, bone defect was replaced with the claimed implant made of porous titanium nickelide, compression osteosynthesis with the claimed brace and two braces with S-shaped backs. All staples are made of an alloy with thermomechanical shape memory, such as titanium nickelide. Sutures were removed on day 14, external immobilization with a scarf bandage, abduction of the arm on a roller in the axillary region. Active movements in the joints (elbow, hand, wrist) started from the first day after surgery. Active movements in the shoulder joint started 3 weeks after surgery. 3 months after surgery, the tone of the muscles of the shoulder corresponds to a healthy limb, there is no malnutrition. When radiological examination of the shoulder joint, the shoulder head is located in the cavity of the scapula, the fracture has grown together, Fig.13b. Movement in the shoulder joint in full. On palpation, there is no pain, the contour element from the bone structures is absent. The patient is satisfied with the result of the treatment. Follow-up examination after 1 year. The results of osteosynthesis are presented on the x-ray, Fig.13c. The effectiveness of the method is recognized as good.

Thus, the proposed method for the surgical treatment of comminuted fracture of the proximal humerus, the implant and the staple for its implementation can improve the efficiency of osteosynthesis due to the possibility of filling the bone deficiency and interfragment compression of fragments in several directions between each other, as well as to the implant through the use of staples of various shapes.

Claims (3)

1. A method for surgical treatment of comminuted fracture of the proximal humerus, including osteosynthesis with a bracket with a back in the form of a loop passing through the lateral arches into the intramedullary legs, and an alloy bracket with a thermomechanical shape memory with an S-shaped back that passes into the legs, drilling holes in areas of the large tubercle of the humerus and the introduction of the intramedullary legs of the staples with a loop-shaped back, matching bone fragments, immersing the staples of the staples in the bone until the lateral arches are bent, installing the staple with an S-shaped the back by drilling holes for the legs above the loop of the back of the previous bracket and on the diaphysis of the humerus; cooling the braces, straightening the S-shaped back, straightening and inserting the legs into the prepared holes, characterized in that after removal of small bone fragments, a cylindrical implant of porous titanium nickelide with an internal through central channel, a semi-cylindrical longitudinal groove on the side surface and through a transverse channel in the proximal part of the cylinder, while installing the implant so that the longitudinal groove was parallel to the side surface of the pl chevoy bone and the lower transverse channel opening on the front surface of the implant was laterally; On the protruding end of the cylindrical implant, the head of the humerus is inserted, bone fragments are placed to restore the shape of the proximal segment of the humerus, opposite the central canal of the cylindrical implant and above the semicylindrical longitudinal groove in the head of the shoulder at the level of a large tubercle, channels under the intramedullary legs of the first bracket are formed ; then use the first bracket made of an alloy with thermomechanical shape memory, the loop-shaped back of the first bracket made of three differently directed loops, the extreme loops are directed loop down, and the central loop is looped up, the extreme loops are bent inside the bracket towards the legs, the arcs are oriented in the direction of the intramedullary legs towards each other, and the intramedullary legs diverge, the bracket is cooled, the loops of the first bracket are stretched by 10-15 mm and removed from the legs, one of the legs is installed through the central channel of the cylinder implant into the diaphysis of the humerus, the second intramedullary leg is installed in a longitudinal groove on the lateral surface of the cylindrical implant, the staples loops are placed above the large and small tubercles, covering them around the perimeter, holes are formed for the upper legs of the second and third staples with an S-shaped alloy back with a thermomechanical shape memory above the loops of the first bracket, directed downward, with one hole being placed at the level of the transverse channel of the implant; holes are drilled for the lower legs of the second and third brackets in the region of the distal fragment of the humerus, the brackets with the S-shaped back are cooled, the bends of the back are straightened to increase the linear size by 10-15 mm, the legs of the S-shaped brackets are installed in the prepared holes, and the upper leg one of the S-shaped staples is inserted into the head of the humerus through the transverse channel of the cylindrical implant. 2. A bracket containing a loop-shaped back, passing through arcs to the intramedullary legs, characterized in that the arcs are curved in the lateral plane lying perpendicular to the plane of the intramedullary legs, the loop-shaped back is made of three oppositely directed loops, the outer loops are directed loop down and the loop up , extreme loops are bent inward of the bracket towards the legs, arcs curved in the lateral plane are oriented in the direction of the intramedullary legs towards each other at an angle of 50 °, intramedullary ozhki diverge at an angle of 15 ° in the plane of the bracket is made from an alloy with thermomechanical shape-memory. 3. An implant made of porous titanium nickelide, made in the form of a cylinder, characterized in that it has an internal through central channel, a semi-cylindrical longitudinal groove on the side surface and a through transverse channel located between the internal through central channel and the semi-cylindrical longitudinal groove, at a distance from the axis implant equal to the radius of the inner through central channel.

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