RU2454962C1 - Method of optimising conditions of knitting of fractions of extremity bones and their consequences in conditions of their immobilisation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely, to traumatology and orthopedics, and can be applied for optimisation of knitting of extremity bones in case of fractures, unknitted fractures or false joints. For this purpose realised is stable osteosynthesis, which includes reposition of bone fragments and their stable immobilisation. After that on 8 - 10 day after operation into the area of bone defect introduced is nitroglycerine in dose to 10 mg, diluted in 2 ml of physiological solution. Immobilisation of bones of damaged segment is preserved until their complete consolidation.

EFFECT: method ensures maximal vasodilatation effect in the zone of injury and due to it acceleration of terms of fracture consolidation and their consequences.

10 dwg, 2 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of fractures of limb bones and their consequences (non-healing fractures, false joints) under conditions of their stable immobilization.

The problem of optimizing and regulating reparative osteogenesis in case of extremity bone fractures and their consequences (non-fused fractures, false joints) is far from an unresolved and practically unsolved problem of modern traumatology and orthopedics.

One of the main directions in the treatment of fractures and their consequences (non-fused fractures, false joints) after their stable immobilization is the creation of conditions conducive to revascularization of bone fragments in the area of damage with their subsequent consolidation.

The process of consolidation of the damaged bone begins with the formation of osteoblastic tissue such as fibroreticular tissue, which fills the interfragmental space, 3-5 days after the injury. The direction of cell differentiation in this period of time is determined by the action of a number of factors, but primarily blood supply, then oxygenation, the intake of vitamins, biologically active substances and other regulators.

In the second period of osteogenesis (6-10 days), bone marrow is formed, microscopically consisting of periosteal and endosteal regenerates formed by osteoid and newly formed cancellous bone tissue. This period is characterized by protein biosynthesis, the intensity of which, first of all, depends on vascularization of the regenerate, enhanced by good oxygenation of the tissue with oxygen. Under conditions of hypoxia, these processes slow down, respectively, the formation of an organic matrix of bone marrow slows down.

Since in the fracture zone, its nonunion or false joint, there is most often a displacement of bone fragments, their mobility, fragmentation of their ends in the form of large or small fragments with a significant violation of vascularization, a decrease in the rate of metabolic processes, all this causes a deviation during periods and a change nature of regeneration.

So, according to Grazhdanova K.A. (Abstracts of the IX congress of traumatologist and orthopedists, Saratov, September 15-17, 2010, p. 117) consolidation of fractures of the humerus after spoke-core osteosynthesis occurs in the interval from 105 to 140 days. After closed osteosynthesis of femoral fractures, the terms of fusion, according to A. Karasev. et al. (ibid., p. 162), make up 98-125 days, and disability reaches 13.4%.

With extensive damage to the vascular network of the periosteum and endosteum during a fracture, its nonunion or false joint, even with absolute immobilization of the fragments, consolidation may not occur, and the ends of the fragments may undergo resorption or avascular necrosis.

The direction of histogenesis of connective tissue cells is determined by the conditions of mechanical stabilization of bone fragments and the degree of their blood supply (Baskevich M.Ya. Actual issues of regeneration of osteoreparation and treatment of fractures. Novosibirsk, 1992, p. 74-75).

The most common methods for optimizing fracture fusion conditions are known, such as:

- electrical stimulation (Emelyanov VG The use of electromagnetic stimulation in the treatment of false joints. Materials of the V All-Russian Congress of Orthopedic Traumatologists. Yaroslavl, 1990, p. 211-212);

- hyperbaric oxygenation (Tikhilov P.M. et al. Effect of oxybarotherapy on bone tissue generation. Orthopedist, traumatologist, 1980, M.12, p.51-52);

- vibroacoustic impact (Nakonechny DG et al. Experimental substantiation of the use of vibroacoustic impact in the treatment of fractures of tubular bones. Traumatology and Orthopedics of Russia, 2009, No. 4, pp. 53-59).

The latter method is accepted by us as a prototype. However, an analysis of publications by domestic and foreign authors showed that when bone fragments are immobilized using various factors affecting osteogenesis, the frequency of unsatisfactory outcomes varies from 10.5 to 20.3%, of which consolidation failure is from 6.4 to 9.4% ( Glukhikh DL Traumatology and Orthopedics of Russia. Materials of the international conference. Moscow, 2005, p.183-184). So, the average terms of consolidation of fragments during osteosynthesis with plates are 12-16 weeks (Meskhi K. T. Bulletin of Traumatology and Orthopedics. 2007, No. 4, p. 15-18), and with intramedullary osteosynthesis - 16 weeks (A. Lukin. Herald of Surgery, 1991, No. 5, p.127-129).

The most promising direction in the stimulation of osteogenesis in fractures, overgrown fractures, and false joints of limb bones is the use of a low concentration solution of nitroglycerin.

The purpose of the invention is the improvement of the treatment results of patients with fractures of limb bones and their consequences (non-fused fractures, false joints) after their stable immobilization.

The goal is achieved by inter-fragment administration of a low-concentration solution of nitroglycerin into the fracture, non-healing fracture, and false joint during the formation of inter-fragment angiogenic bone tissue, on average, for 8-10 days after the start of stable fixation of fragments.

The essence of the invention lies in the fact that a low-concentration solution of nitroglycerin (10 mg per 2 ml of water for injection) is proposed to be used in traumatology and orthopedics in a new direction, namely, by introducing into the fracture area to eliminate tissue hypoxia, improve the rheological properties of blood in the area of damage, reducing aggregation ability of red blood cells and platelets. Experimental studies of A. Zubov (The use of a solution of nitroglycerin in the complex treatment of degenerative diseases of the hip joint in adults. Abstract of the dissertation Candidate of Medical Sciences, M., 2000, p. 18) showed that intravenous administration of nitroglycerin increases the flow of arterial blood to the site of bone tissue destruction due to antispasmodic effect of nitroglycerin on the smooth muscles of arterial vessels. However, for fractures of limb bones, intravenous administration is unacceptable due to possible side complications, such as a decrease in blood pressure, orthostatic collapse, and impaired cardiac activity. The most optimal according to the claimed method is the local injection of the drug directly into the area of nonunion.

The local use of a low-concentration solution of nitroglycerin as a means to optimize the conditions for the healing of fractures, non-fused fractures, and false joints of limb bones is carried out as follows.

After 8-10 days after the start of immobilization of the fracture, non-healing fracture, pseudoarthrosis of the limb bones, using any of the existing methods, 10 mg of nitroglycerin are collected in a syringe, which is mixed with 2 ml of physiological saline. Before the introduction of the patient, blood pressure is measured, they are given a horizontal position. The prepared low-concentrated nitroglycerin solution (2 ml) is injected very slowly through a needle under the EOP into the subperiosteal or directly into the fracture, non-healing fracture, of the false joint. After slow administration of the drug, the patient is closely monitored. 10 minutes after administration, blood pressure is re-measured. The patient maintains a horizontal state for 40-60 minutes.

If the injured limb was in a plaster cast or orthosis before the introduction of a low concentrated solution of nitroglycerin, then after the introduction they are stored until the previously established time with the implementation of the postoperative regimen.

As a clinical example, the following observation. Patient G.G. (46 years old, IB 4817) as a result of a fall on 05/08/2009, he received an injury to his left leg. I did not seek medical help. In connection with the intensification of pain and the inability to load the injured limb, the patient on 12.05.2009 independently applied to the admission department of the City Clinical Hospital No. 59 in Moscow. Clinical x-ray examination was diagnosed as a closed multifinished fracture of the left tibia from the middle to the lower third with a displacement of bone fragments (figure 1). Post-traumatic deforming arthrosis of the left ankle joint. A skeletal traction for the calcaneus with a load of 7 kg was imposed on the patient in the admission department. Hospitalized in the 7th orthopedic department. After a comprehensive examination of the patient on May 21, 2009, the operation was performed: an open reposition of bone fragments with bone osteosynthesis with a plate and screws (Fig. 2a, b). The posterior plaster cast is applied from the fingertips to the upper third of the lower leg. The postoperative period was uneventful. In order to optimize the conditions of fusion of a multi-fragmented fracture, the patient was administered 10 mg of nitroglycerin diluted with 2 ml of physiological solution in the fracture area on May 28, 2009. The postoperative wound healed by first intention, the sutures were removed on the 16th day, the patient was discharged from the hospital with immobilization of the posterior plaster cast, recommending walking on crutches without loading the operated limb. Examined 1.5 months after the operation (07/07/10) with x-ray control (figa, b). There was a consolidation of the fracture. The patient is allowed to walk on crutches with a full load on the operated limb up to 2 months after surgery, and then with a cane.

Clinical and radiological control of the result of treatment 4 months after surgery. On radiographs of the bones of the left tibia (figa, b) from 09/30/10 full fusion of the fracture area with restoration of the bone marrow canal and the continuity of the cortical walls of the tibia. There are no signs of resorption at the points of contact of the plate and screws (Fig. 4). The supporting and motor functions of the left lower leg and ankle joint are complete (Figs. 5, 6 and 7).

This nitroglycerin solution is particularly effective in the treatment of pseudoarthrosis and defects of long bones of the extremities. The following clinical observations are cited as convincing evidence.

Patient S.G., 69 years old, and.b. 6417, was admitted to the XIth orthopedic department of the City Clinical Hospital No. 59 in Moscow with complaints of pain, deformity, restriction of movements in the region of the left shoulder joint. From the anamnesis it is known that the patient in February 2007, when falling on the left shoulder, received a fracture of the humerus of the humerus. She was hospitalized in the traumatology department of the City Clinical Hospital No. 29 in Moscow, where after a clinical and radiological examination she was operated on - open bone osteosynthesis in / h of the humerus. The postoperative period was uneventful. It was observed in the trauma center for 3.5 years. Coalescence did not occur. 06/16/2010, the orthopedic department of hospital No. 59 was hospitalized in XI with a diagnosis of a false joint of the upper third of the left humerus, instability of bone osteosynthesis, osteolysis, migration of plates and screws (Fig. 8).

After clinical and radiological examination 06/28/10, the patient underwent surgery: removal of metal structures, resection of the false joint in / h of the humerus with telescopic autoplasty with segmental graft from the fibula and bone osteosynthesis with angular stability (Fig.9). The postoperative period without features. On the 8th day after the operation of the patient, 10 mg of nitroglycerin dissolved in 2 ml of water for injection was injected into the autoplasty area. Postoperative wounds healed by first intention. The patient was discharged for outpatient treatment with immobilization of the left upper limb with an orthosis. Clinical and radiological control 2 months after surgery (09/30/10). The function of the left shoulder joint is complete, painless. On the roentgenogram of the left shoulder joint, the consolidation of the false joint of the upper third of the humerus is determined (figure 10).

The proposed method for optimizing the conditions of fusion is recommended for the treatment of adult patients with fractures of limb bones and their consequences. Its use in the clinic of traumatology and orthopedics will significantly reliably accelerate the consolidation of fractures and their consequences compared to the known ones, provide early activation of the patient while maintaining stable osteosynthesis for the entire period of bone healing.

Figure 1 shows a comminuted fracture of the lower third of the left tibia in a direct projection of the patient G.G., 46 years old, and.b. 4817.

Figure 2 shows a comminuted fracture of the lower third of the left tibia of the same patient in the direct (a) and lateral (b) projections after the bone osteosynthesis with a plate dated 05/21/2009.

Figure 3 shows a consolidated fracture of the lower third of the left tibia in the direct (a) and lateral (b) projections of the same patient after bone osteosynthesis with a plate and an injected nitroglycerin solution.

Figure 4 shows the full fusion of the fracture of the lower third of the left tibia of the same patient with the restoration of the length of the bone marrow canal and the continuity of the cortical wall 4 months after surgery (a - direct projection, b - lateral projection).

Figure 5 presents a photo of the same patient - a side view, with full support on the foot 4 months after the bone osteosynthesis of a fracture of the lower third of the left tibia and a nitroglycerin solution introduced into the fracture region.

Figure 6 presents a photo of the same patient - a rear view, with the function of the operated left leg (bone osteosynthesis of a fracture of the lower third of the tibia with a plate and the introduction of nitroglycerin solution into the fracture region) with full support on the forefoot.

Figure 7 presents a photo of the same patient - a side view, with full support on the front foot of the healthy (right) and operated (left) lower leg.

On Fig presents a radiograph of the left shoulder joint in a direct projection of the patient S.G., 69 years old, and.b. 6417 with a pseudoarthrosis of the upper third of the humerus, the condition after bone osteosynthesis. Osteolysis of bone fragments, plate and screw migration.

Figure 9 presents the x-ray of the left shoulder joint of the same patient after removal of metal structures and telescopic autoplasty with a segmental graft from the fibula and bone osteosynthesis with angular stability from 06/28/2010.

Figure 10 presents the x-ray of the left shoulder joint of the same patient 2 months after surgery (09/30/10) and the introduction of a solution of nitroglycerin. Consolidation of the pseudoarthrosis of the upper third of the humerus.

Claims (1)

A method for optimizing the conditions of limb fusion in fractures, non-fused fractures or false joints, including stable osteosynthesis and administration of a drug, characterized in that after reposition of bone fragments and their stable immobilization, they are introduced into the area of the bone defect on the 8-10th day after operations nitroglycerin in a dose of up to 10 mg, diluted in 2 ml of physiological saline, while maintaining immobilization of the bones of the damaged segment until they are fully consolidated.

Images