RU2432138C1 - Method of minimally invasive external fixation of long bones and external fixation device - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to medicine. It involves a closed reduction of fragments of an injured bone. The injured bone is approached from an incision approximately 3-5 cm long above a distal fragment. A bed is formed for the following introduction of a bone portion of the device. The device is assembled by parallel connection of two opposed longitudinal identical plates - bone and external - movable relatively to each other by a hollow rod through their border holes. The latter have extended lines of threaded tapered holes of the same size. Along the full length, the rod has an external thread which comprises movable fixation elements to fix a position of the plates in the form of conical nuts aligning the rod in the holes of the plates. A distal working end of the rod has a flange in the form of a truncated cone with its greater base directed towards a proximal end of the rod and having the sizes and an external thread provided on an external surface, matched with those of the holes of the plates. The bone plate is introduced into the formed bed. The bone plate is fixed to a distal fragment of the injured bone with a wire inserted through a rod cavity. The assemblage process is finished by coupling the free ends of the plates by a second similar hollow core in their matched holes through a puncture above the proximal fragment. The bone plate is fixed to the proximal fragment of the injured bone by another wire through a cavity of the second rod. Then using the holes of the external and bone plates as a navigation system, the holes are formed of skin punctures up to 1 cm in the injured bone, and the bone plate is screwed therethrough to the fragments of the injured bone. Then the external plate, the rod and the wires are removed. Fixation of the bone plate is finished by screw insertion in the empty holes. ^ EFFECT: invention reduces blood loss, risk of infectious complications, a number of intraoperative X-ray examinations and X-ray action on the personnel and the patient, reducing thereby length of the surgical intervention. ^ 2 cl, 1 ex, 1 dwg

Description

The invention relates to medicine, namely to traumatology, and is intended for the treatment of fractures of long bones, such as a femur.

A known method of minimally invasive osseous osteosynthesis of long bones, in particular a fracture of the lower third of the tibia [Litvinov II, Klyuchevsky V.V. Minimally invasive osteosynthesis with closed fractures of the lower third of the tibia // Bulletin of Traumatology and Orthopedics. N.N. Priorov. 2006. No1. S.13-17]. The implementation of this method is carried out under constant visual control on a monitor of an electron-optical transducer of an x-ray image (image intensifier tube). Above and below the fracture zone, access is made to the outer surface of the proximal fragment of the damaged bone. Between the two accesses, a tunnel is stupidly formed along the anteroposterior surface of the bone, through which a pre-modeled lockable plate is introduced from the bottom up. Produce preventive indirect manual reposition. Then, the plate is positioned on the bone and fixed to the distal fragment of the damaged bone through a non-threaded hole with a pulling spongy screw. Through the sleeve screwed into the distal threaded hole, enter the Kirschner needle to mark the position of the distal locking screw relative to the fracture line. An opening is formed in the proximal fragment outside the plate, by which the displacement along the length is eliminated by the use of a distraction device. The position of the achieved correction is fixed with another Kirschner spoke inserted through the sleeve in the threaded hole of the proximal end of the plate. Perform control x-ray. Eliminate deformation in the frontal plane by removing the Kirchner knitting needle from the distal fragment and loosening the spongy screw by turning around the last lower fragment of the damaged bone. Then the spongy screw is tightened again. The final fixation is performed by inserting blocking screws into the distal fragment through the threaded holes, into the proximal fragment - the monocortical attracting screw until the edge of the plate contacts the bone and the monocortical screws with angular stability.

However, the fixation of the plate is made from two cuts. The determination of the points where the plate holes through soft tissues are located is difficult. The use of constant visual control on the monitor of an electron-optical converter of an x-ray image (EOP) during all stages of an operative measure increases the amount of x-ray exposure of the medical staff and the patient, as well as increases the operation time.

A known method of minimally invasive osseous osteosynthesis of long bones, in particular the tibia [RU patent for invention No. 2093094]. Match fragments of damaged bone. The plate is superimposed on the fracture zone by passing it using a holder with a guide rod through a transverse section of soft tissues with a width corresponding to the width of the plate. Screws are inserted through the skin incisions into the fragments and they fix the plate to the bone.

The closest analogue to the claimed method is the “Method of minimally invasive bone osteosynthesis of diaphyseal fractures of tubular bones” [RU patent for invention No. 2348371]. Closed manual reposition is performed to eliminate coarse bias and interposition of soft tissues. A skin incision is made about 4 cm long above the distal fragment. A blunt long raspator produces the formation of a bed for the plate by sliding along the surface of the bone. The matched plate is modeled by clamping the distal end with a screw clamp. Mark the projection of the plate holes on the guide frame of the device on a graduated scale using a movable slide-guide. The fixed plate is inserted into the bed formed by the raspator. They are fixed with screw rods, one of which is inserted into the distal fragment to the second cortical layer, then fixed to the guide frame. The second screw-rod is inserted into the proximal fragment with a deviation of 15-20 degrees in the sagittal plane 2-3 cm proximal to the fracture site, after which it is also fixed to the guide frame. Using nodes located on the screw nozzle, the offset in width, rotational and angular displacements, as well as displacement in length by compression along the screw nozzle, are eliminated. After achieving reposition, all nodes of the guide frame are rigidly fixed. According to the projections of the plate openings previously marked on the graded scale of the guide frame, a movable guide slider is installed, through which a protector guide and a trocar are introduced. Dots are marked on the skin, a soft tissue incision is made. The protector guide with the trocar is immersed in the incision to the cortical layer of the bone. The trocar is removed, a guide for the drill is introduced, through which a hole is drilled through two cortical layers. A screw length gauge is inserted into the hole drilled in the bone, then a specific screw is screwed into the drilled hole through a tread guide using a screwdriver. The remaining screws are inserted in a similar manner. The distal end of the plate is released, loosening the fixing screw, the rod screws are removed.

However, the use of a mobile guide slide in this method and making cuts according to pre-marked marks after reposition of fragments reduces the accuracy of inserting screws into the holes of the osseous plate, increases the time for surgery due to an additional search for holes in the plate, and increases the invasiveness of soft tissues.

There are various modifications of devices for performing osteosynthesis of long bones [copyright certificate SU for invention No. 1502020, RU patents for invention No. 2093100, No. 2133594, No. 2210335, No. 2223062]. All of them are made in the form of osseous plates with threaded holes for screws.

The closest analogue to the claimed in this application device is a device for performing bone osteosynthesis of long bones with minimally invasive access, described in patent RU for invention No. 2093094. It contains the bone and external parts. The osseous part is made in the form of a plate with a screw hole. One end of the plate is blunt, and the other has a point. The outer part of the device is a holder with a guide rod and a fastening element for the blunt end of the plate. The screw hole in the plate is made in the form of a longitudinal groove.

However, this device is difficult to manufacture and is not available for a wide range of orthopedic traumatologists, unlike industrially produced analogues. There are no external marks in the guide frame corresponding to the holes in the plate.

The objective of the invention is to reduce trauma to soft tissues while reducing the time for surgery and reducing postoperative infectious complications and blood loss.

The essence of the proposed method minimally invasive osseous osteosynthesis of long bones is characterized by the fact that they make a closed reposition of fragments of the damaged bone, access the damaged bone using an incision about 3-5 cm long above the distal fragment, form a bed for subsequent insertion of the bone part of the device, and assemble the device by connecting parallel to each other two longitudinal identical plates - the osseous and external hollow rod through their edge openings with the possibility of ensure the movement of the plates relative to each other, insert the osseous plate into the formed bed, fix the osseous plate to the distal fragment of the damaged bone with a spoke, passing it through the cavity of the rod, complete the assembly of the device by connecting the free ends of the plates with a second hollow rod into their corresponding holes through a puncture cut above the proximal fragment, fix the osseous plate to the proximal fragment of the damaged bone with the second spoke through the cavity of the second rod, then, using Opening the holes of the external and bonded plate as a navigation system, holes are formed in the damaged bone from punctures of skin up to 1 cm and the bonded plate is fixed through them to the broken bone fragments with screws, after that the external plate, rods and knitting needles are dismantled, the fixation of the bonded plate is completed by installation screws into the freed holes.

The essence of the claimed device for bone osteosynthesis is characterized by the fact that it is made in the form of two identical longitudinal plates oriented in parallel with each other and with angular stability - bone and external with long rows of threaded conical holes of the same size, the plates are interconnected to move one relative to the other hollow rods with a diameter smaller than the diameter of the holes of the plates with the possibility of free passage of the rods through them, while throughout An external thread is applied on the rods of the rods, on which movable fasteners are installed to fix the position of the plates in the form of conical nuts that center the rods in the holes of the plates, and a protrusion of the shape of a truncated cone oriented with a large base towards the proximal end of the rod is made at the distal working end of each rod having an external thread dimensioned and applied to its outer surface, corresponding to the dimensions and internal thread of the plate openings.

The technical result of the claimed invention consists in solving the problem posed earlier by increasing the accuracy of introducing fixation elements of the osseous metal structures while maintaining adequate blood supply to both the fracture area and the entire segment throughout the installed plate. The implementation of small punctures-cuts of the skin up to 1 cm long without additional trauma to the soft tissues allows the installation of a bone plate without the risk of damage to the soft tissues. The set of signs of the implementation of the proposed in this application method reduces blood loss, the risk of infectious complications, the number of intraoperative x-ray studies and the effect of x-ray radiation on medical personnel and the patient, thereby reducing the time for surgery. The use in this method of a device made in the form of two identical plates connected with the possibility of regulating the distance between them with angular stability of different sizes allows bone osteosynthesis with different fracture localization for patients of different physique (high, low, thin, full) and age. These plates are manufactured by the industry and are available for a wide range of orthopedic traumatologists.

The invention is illustrated using the drawing, which shows a General view of the device for bone osteosynthesis. In the drawing, positions 1-6 indicate:

1 - a bone plate;

2 - an external plate;

3 - holes of the plates;

4 - rods;

5 - mobile fasteners;

6 - ledge.

The device for osseous osteosynthesis includes two identical longitudinal plates with angular stability oriented parallel to each other - osseous 1 and outer 2 with long rows of threaded conical holes 3 of the same size. The plates 1, 2 are interconnected with the possibility of moving one relative to the other along the vertical axis of the hollow rods 4 with a diameter less than the diameter of the holes 3 of the plates 1, 2 with the possibility of free passage of the rods 4 through them. Over the entire length of the rods 4, an external thread is applied on which movable fastening elements 5 are installed to fix the position of the plates 1, 2 in the form of conical nuts, centering the rods 4 in the holes 3 of the plates 1, 2. A protrusion 6 is made on the distal working end of each of the rods 4 the shape of a truncated cone, oriented by a large base towards the proximal end of the rod 4 and having dimensions and an external thread applied to its external surface corresponding to the dimensions and internal thread of the plate openings.

The method of minimally invasive osseous osteosynthesis of long bones is as follows.

Lay the patient on the operating table. A closed reposition of fragments of damaged bone is performed. After processing the surgical field, a skin incision is made 3-5 cm long above the distal fragment, departing from the fracture site on the order of 5-7 cm. Then, a bed is formed using the elevator for subsequent insertion of the plate 1 by sliding it over the bone surface. Two parallel identical plates are connected in parallel opposite each other - the osseous 1 and the outer 2 with a hollow rod 4 through their extreme holes 3, eliminate the offset and fix the position relative to each other by fastening elements 5 in the form of conical nuts. Bone plate 1 is introduced into the formed bed in the proximal, then in the distal direction, immersing it under the muscles and centering on the fracture line. Then, the osseous plate 1 is fixed to the distal fragment of the damaged bone with a spoke drawn through the cavity of the rod 4. Designing the center of one of the holes 3 of the external plate 2 above the proximal fragment, a point is marked on the skin and a soft tissue puncture is made about 1 cm above the proximal fragment of the damaged bone . Through the latter, the second hollow rod 4 is fixed into the hole 3 of the osseous plate 1 at right angles to it. The proximal end of the second rod 4 is fixed in the corresponding hole 3 of the outer plate 2. Then, the free end of the osseous plate 1 is fixed using the second spoke through the cavity of the second rod 4. The outer plate 2 is installed parallel to the osseous plate 1, centered and fixed using conical nuts on rods 4 at a level of about 2-3 cm above the skin. Using a trocar and a drill, using the holes 3 of the outer 2 and bone 1 plates as a navigation system, holes in the damaged bone are formed from skin punctures up to 1 cm and the bone plate 1 is fixed through them to the broken bone fragments using screws. Dismantle the outer plate 2, the rods 4 and the spokes in the reverse order of their installation. Screws are inserted into the free holes 3 of the osseous plate 1. The wound is sutured in layers. A control x-ray is made in two projections.

Example.

Patient K., 42 years old, was injured in an accident. He was admitted for treatment to the clinic of traumatology with the diagnosis: “Closed fracture of the middle third of the left thigh”.

Conservative treatment for 7 days was ineffective. After preparation, the patient underwent surgery: minimally invasive bone osteosynthesis according to the method described above. The skin incision was 5 cm and 10 puncture incisions were 1 cm each. The postoperative period was uneventful. The limb load from 20% of body weight 10 days after surgery increased to full by 2 months. As a result of treatment, fusion of fragments occurred after 6 months.

Claims (2)

1. A method for minimally invasive osseous osteosynthesis of long bones, characterized in that they make a closed reposition of fragments of the damaged bone, access the damaged bone using an incision of the order of 3-5 cm above the distal fragment, form a bed for subsequent insertion of the bone part of the device, and assemble the device by connecting in parallel opposite each other two longitudinal identical plates - the osseous and external hollow rod through their edge openings with the possibility of providing alternating The plate openings are relative to each other, insert the osseous plate into the formed bed, fix the osseous plate to the distal fragment of the damaged bone with a spoke, passing it through the cavity of the rod, complete the assembly of the device by connecting the free ends of the plates with the second hollow rod into their corresponding holes through the puncture incision above proximal fragment, fix the osseous plate to the proximal fragment of the damaged bone with the second spoke through the cavity of the second rod, then using the holes of the external she and the osseous plate as a navigation system, form holes in the damaged bone from punctures of the skin up to 1 cm and fix the osseous plate through them to the fragments of the damaged bone with screws, then remove the outer plate, rods and spokes, complete the fixation of the osseous plate by installing screws in vacant holes. 2. A device for osseous osteosynthesis, characterized in that it is made in the form of two identical longitudinal plates with angular stability oriented parallel to one another, osseous and external with extended rows of threaded conical holes of the same size, the plates are interconnected to move one relative to the other hollow rods with a diameter less than the diameter of the holes of the plates with the possibility of free passage of the rods through them, while the entire length of the rod an external thread is applied on which movable fasteners are installed to fix the position of the plates in the form of conical nuts that center the rods in the holes of the plates, and a protrusion of the shape of a truncated cone oriented with a large base towards the proximal end of the rod and having dimensions and the external thread applied to its external surface, corresponding to the dimensions and internal thread of the plate openings.

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