RU2463988C1 - Method of osteosynthesis of hip bone neck with non-free bone autoplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, in particular to traumatology and orthopedics. Open reposition of fragments of hip bone neck is performed. Rigid stable fixation with compression of bone fragments by means of cannulated screws is carried out. Bone autotransplant is separated from iliac bone crest on permanent musculo-vascular feeding pedicle 4 cm wide, including axial vascular bundle with permanent branch of superior gluteal artery with diameter larger than 1 mm, which is exposed from anterior portion of gluteus medius muscle without its distal excision. Non-free transplantation of bone fragment is performed with its placement in prepared groove, located parallel to hip neck axis. Anterior end of autotransplant is introduced into preliminarily formed slot in hip bone head and additionally fixed with screw.

EFFECT: method ensures consolidation of fracture of hip bone neck, reduction of operation trauma, reduction of risk of possible disorders of bone autotransplant blood supply and improvement of blood supply of hip bone head, additional fixation of fragments by means of bone autotransplant.

Description

The invention relates to medicine, in particular to traumatology and orthopedics. It can be used during surgical treatment of patients with fractures of the femoral neck.

Due to the unfavorable environmental situation, worsening injuries and the development of osteoporosis in middle-aged and elderly people, the frequency of femoral neck fractures remains quite high and, according to various authors, is 5.5-9% of all injuries of the musculoskeletal system (Okhotsky V.P. 1995, Cummings SR, 2002). According to A.V. Voitovich, (1996), the frequency of femoral neck fractures is 7.1% of all bone fractures of the lower extremities.

There is a clear tendency to increase both the absolute number of neck fractures of the femur and the specific share of fractures of this localization among the total number of injuries of the musculoskeletal system.

According to the results of studies conducted in Russia, fractures of the proximal femur occur in 100.9 cases per 100 thousand people and their number is constantly increasing (Geraskina T.V., Glybochko P.V., 2000; Mikhailov E.E. et al. , 1999; Zeitlin O.Ya., 2003; Krivova A.V. et al., 2006).

With age, the risk of getting a proximal femur fracture increases, and at 50 years old is 1.8%, at 60 years old - 4%, at 70 years old - 18% and at 90 years old - 24% (Honton J.L., 1986).

With a fracture of the femoral neck, blood supply to the femoral head is disrupted, which leads to delayed consolidation of bone fragments or the formation of false joints in 18-35% of cases (Pliev D.G., 2009, Parker, 1994; Johansson, 2004). Failure to fracture the femoral neck leads to disability and permanent disability of the victims, and in elderly patients it often leads to death during the first year after an injury. Therefore, the development of new methods of osteosynthesis in such fractures that provide reliable fixation of bone fragments and improve blood supply to the femoral head remains an urgent task of modern traumatology.

Close to the proposed method in terms of technical essence and functional purpose, there is a known method of treating a femoral neck fracture by osteosynthesis with cannulated screws with the introduction of a hydroxyappatite suspension through the screw channels (Patent for the invention RU 2148383 C1), which can be considered as an analogue. However, this method has the following disadvantages:

- when performed without arthrotomy and exposure of the fracture zone, it is often impossible to make an exact anatomical reposition of bone fragments, and inaccurate reposition leads to a decrease in the contact surface between the fragments and complicates their subsequent consolidation;

- without opening the joint capsule, it is impossible to fully evacuate the intraarticular hematoma and check the stability of fixation of bone fragments;

- when cannulated screws are inserted after the end of the screw reaches the fracture line, the guide needle is removed, which significantly reduces the stability of the reposition performed and can lead to repeated displacement of bone fragments during further manipulations;

- the introduction of a suspension of hydroxyappatite into the fracture zone causes an additional increase in intra-articular pressure, which adversely affects the blood supply to bone fragments and can disrupt contact between them due to penetration into the interfragment zone;

- in addition, a suspension of hydroxyappatite is essentially a foreign body, which increases the risk of purulent-septic complications in the postoperative period.

The closest in technical essence to our proposed method is a method of treating a defect in the proximal femur using non-free plastic surgery of the periosteal autograft from the iliac crest on a distal feeding muscle leg formed from the anterior middle gluteus muscle (Patent for invention RU 2003298 C1), which considered by us as a prototype.

It should be noted that the method of formation and non-free transplantation of a blood-supplying bone autograft from the iliac crest on a constant feeding leg from the anterior middle gluteus muscle described in the prototype has a number of disadvantages and can be improved. In particular, the prototype method has the following disadvantages:

- the nourishing muscle leg of the blood-supplying bone autograft is very massive: its width is 6-9 cm, which makes its formation rather traumatic;

- during the isolation of the bone autograft to increase its mobility and increase the arc of rotation, the distal end of the muscle leg is cut off below the entry of the feeding branches of the upper gluteal vessels, which increases the risk of their damage, and is also fraught with the development of bleeding and the formation of a hematoma;

- if there is a non-free transplantation of a blood-supplying bone autograft to the reconstruction zone, there is a real risk of torsion and compression of the supply branches of the superior gluteal vessels, which are not protected by a distally dissected muscle leg, which can lead to a violation of the blood supply to the displaced fragment of the ilium.

It should also be noted that the non-free transplantation of a blood-supplying bone autograft from the iliac wing on a constant feeding muscle leg provides bone fragments that retain their own vascular supply and can improve nutrition of the proximal femur to the reconstruction zone. Therefore, such a bone graft is suitable not only for the replacement of defects of the specified localization, but can also be used for osteosynthesis in hip fractures in order to increase the stability of fixation of bone fragments and improve blood supply to the femoral head, which is the essence of our method.

To justify the method, we conducted a special topographic and anatomical study on 12 fixed limbs of 7 corpses of people aged 47 to 67 years. During its implementation, precision preparation of arterial vessels was carried out, passing in the front portion of the middle gluteus maximus muscle. In addition, we performed the modeling of blood-supplied bone autografts from the iliac crest on a permanent muscular-vascular feeding leg according to our method, which implied their non-free transplantation into the femoral neck and use for osteosynthesis in case of its fractures.

The applied topographic and anatomical studies have made it possible to establish that in the front portion of the middle gluteus muscle 4 cm wide, one or two axial vascular bundles, which are branches of the superior gluteal vessels, always pass. Moreover, each of these bundles consists of an artery with a diameter of 1 to 1.8 mm and associated veins, is located parallel to the muscle fibers and reaches the iliac crest along its outer surface (Fig. 1). Therefore, the width of the muscular-vascular feeding leg of the blood-supplied bone autograft from the iliac crest can be 4 cm, which is quite enough for its nutrition, taking into account the topography and diameter of the blood vessels passing in the front portion of the middle gluteal muscle.

Modeling of the proposed operation of osteosynthesis of the femoral neck with non-free bone autoplasty on anatomical material showed that with a width of the feeding muscle-vascular pedicle of 4 cm, its length can be from 10 to 12 cm. In this case, a bone autograft from the iliac crest can be transplanted into the neck thighs with preservation of the vessels supplying it without cutting off the muscle leg below the branches of the superior gluteal artery and vein entering it (Fig. 2).

The technical result of the proposed invention is the consolidation of a fracture of the neck of the femur, reducing the morbidity of the operation of non-free bone autoplasty due to transplantation of a blood-supplying bone fragment on a relatively thinner constant feeding muscle-vascular leg, reducing the risk of possible circulatory disorders of the bone autograft associated with torsion and compression of the supply branches of the upper gluteal vessels, which in our version are protected by a preserved muscle leg, highlighted without its distal cut, and additional fixation of bone fragments using autograft bone and improve the blood supply of the femoral head due perfused transplanted bone fragment to prevent disturbances of bone fragments consolidation.

The result is achieved due to the fact that the arthrotomy of the hip joint, the open reposition of fragments of the femoral neck, the evacuation of intraarticular hematoma, the introduction and the gradual successive tightening of the cannulated screws are performed first. Then, a bone groove and a groove in the femoral head are formed on the front surface of the femoral neck parallel to its axis. Next, a blood supply autograft is isolated from the iliac crest 6 × 1.5 × 1 cm in size, retreating 2-3 cm posterior to the upper anterior ilium, and without feeding cut it forms its nourishing muscular-vascular leg 10-12 cm long and 4 cm wide including the front portion of the middle gluteus muscle and the axial vascular bundle with a constant branch of the superior gluteal artery with a diameter of more than 1 mm. Then, the formed blood-supplying bone autograft is transplanted to the neck of the femur on a constant supply muscle-vascular leg, it is placed in the prepared bone groove with the front end inserted into the pre-formed groove in the femoral head and fixed with a screw in the intertrochanteric region, which provides additional fixation bone fragments and improves blood supply to the femoral head.

It should be noted that the muscle-vascular feeding leg of a bone autograft with a width of only 4 cm, isolated without distal intersection according to our methodology, is guaranteed to include sufficiently large axial feeding vessels and ensures reliable blood supply to the transplanted bone fragment. At the same time, the feeding leg, twice as narrow as the prototype, is more plastic and allows the blood-supplying fragment of the iliac crest to be transplanted into the femoral neck without dangerous kinks and compression of the branches of the superior gluteal vessels. In addition, the preservation of the distal part of the muscular-vascular pedicle, which, unlike the prototype, does not intersect, protects the vessels supplying the bone fragment, helps to reduce the risk of eating disorders and reduces the invasiveness of the operation.

In contrast to the analogue, the proposed method for osteosynthesis of the femoral neck with non-free bone autoplasty involves opening the capsule of the hip joint, which allows you to completely evacuate the existing hematoma in order to decompress and improve blood supply to bone fragments, as well as to make a full reposition and reliable fixation of them with cannulated screws. In addition, a blood-supplied autograft from the iliac crest, transplanted in a non-free version on a constant muscular-vascular feeding leg, provides additional fixation of bone fragments and improves their blood supply.

Thus, our proposed technique for osteosynthesis of the femoral neck with non-free bone autoplasty has significant differences from both the analog and the prototype.

The figures depict:

Figure 1. The result of the preparation of the nourishing muscle-vascular leg after the formation of the right leg and pelvis of the bone autograft from the iliac crest according to the proposed method, where 1 is the nourishing branch of the superior gluteal artery, 2 - muscle leg from the front portion of the middle gluteal muscle 4 cm wide , 3 - isolated bone autograft.

Figure 2. The result of modeling the proposed operation on the preparation of the right lower limb and pelvis, where 2 is the muscle leg from the front portion of the middle gluteus muscle 4 cm wide, 4 is the screw head fixing the distal graft in the groove on the femoral neck. The selected fragment from the iliac crest was transplanted into the neck of the femur on a constant muscular-vascular pedicle, placed in a pre-made bone groove, inserted with its front end into a pre-prepared groove in the femoral head and additionally fixed with a screw in the intertrochanteric region.

Figure 3. Scheme of the proposed operation to the stage of non-free bone grafting: 5 - the boundaries of the formation of a bone autograft from the iliac crest; 6 - fibers of the middle gluteal muscle with an axial feeding vascular bundle; 7 - cannulated screws inserted to fix a fracture of the femoral neck.

Figure 4. Scheme of the proposed operation after performing the stage of non-free bone grafting, where 2 is the constant supplying muscular-vascular pedicle preserved after transplantation, 3 is the autograft from the ilium crest displaced and fixed in the femoral neck.

Figure 5. Radiograph of the right hip joint of patient S., 48 years old, in anteroposterior projection 3 hours after the injury leading to a transcervical fracture of the right femur.

Figure 6. Radiograph of the right hip joint of patient S., 48 years old, in axial projection 3 hours after the injury.

Figure 7. Radiograph of the right hip joint of patient S., 48 years old, in anteroposterior projection immediately after performing the proposed operation for osteosynthesis of the femoral neck with non-free bone autoplasty.

Figure 8. Radiograph of the right hip joint of patient S., 48 years old, in axial projection immediately after performing the proposed operation of osteosynthesis of the femoral neck with non-free bone autoplasty.

Figure 9. On the radiograph of the right hip joint in the anteroposterior projection in patient S., 48 years old, consolidation of bone fragments 8 months after the proposed operation.

Figure 10. On the radiograph of the right hip joint in axial projection in patient S., 48 years old, consolidation of bone fragments 8 months after the proposed operation.

The proposed method is as follows.

First, an anterior section of the ilium crest, anterior portion of the middle gluteus muscle attached to it, an arthrotomy of the injured hip joint, and an intraarticular hematoma are evacuated in an arcuate incision from the anterior superior ilium to the anterodermal region. Next, fragments of the femoral neck are found and their anatomical reposition is performed. Then, under the control of the electron-optical converter, three threaded spokes are carried out from the region of the slope under a large trochanter through the femoral neck into the femoral head. Bone channels are formed through them with a hollow drill, which are treated with a cannulated tap without removing the needles. Next, three cannulated screws with an end thread of 6.5 mm and a length of the threaded part of 16 or 32 mm, depending on the size of the femoral head fragment, are sequentially passed through the formed channels. The screws are tightened in turn, creating the necessary rigid fixation and compression of the bone fragments. Then control the stability of osteosynthesis by traction with single-tooth hooks in the fracture zone. In case of detection of instability of fixation, cannulated screws are repeated until a rigid fixation is created.

As the next step, on the front surface of the femoral neck parallel to its axis, the future bed of the bone autograft is formed with an osteotome - a bone groove 6 × 1.5 × 1 cm in size. A groove is formed in the femoral head with a drill 1.0-1.5 cm long and about 1 wide , 5 cm. Then, a bone autograft is formed from the anterior iliac crest 6 × 1.5 × 1 cm in size, retreating 2-3 cm posterior to the superior anterior ilium. In this case, only the outer cortical plate of this bone is removed with the adjacent layer of spongy bone tissue (Fig. 3). The bone fragment is taken by the osteotome in such a way as to preserve the fibers of the anterior portion of the middle gluteal muscle attached to it, in which the branches of the superior gluteal vessels that feed the bone pass. Then carefully form the muscle-vascular feeding leg of the autograft with a width of 4 cm, a thickness of 1-2 cm and a length of 10 to 12 cm with an axial vascular bundle passing in its thickness.

At the next stage of the operation, the bone autograft is deployed anteriorly on the feeding muscle-vascular pedicle by approximately 90 °, it is lowered and placed in the bone groove previously prepared on the front surface of the femoral neck. At the same time, the inner spongy part of the autograft is adapted to the receiving bone bed and completely covers the fracture zone. The front end of the transplanted bone fragment is separated from the muscle leg for 1-1.5 cm, adapted in shape to the bone groove in the femoral head and inserted into this groove with a tight impact. The posterior end of the bone autograft is fixed to the femur in the intertrochanteric region with a cortical screw (Fig. 4). The surgical wound is sutured in layers, leaving two drains: at the bed of the bone autograft and in the subfascial layer.

Clinical example: Patient S., 48 years old, was admitted to the clinic. R.R.Vredena regarding a transcervical fracture of the neck of the right femur (Garden IV) with a pronounced displacement of bone fragments (Figs. 5, 6). He underwent osteosynthesis of the neck of the right femur with cannulated screws with non-free bone autoplasty according to our proposed technique. During the operation, an arthrotomy of the right hip joint, evacuation of an intraarticular hematoma, an open reposition of fragments of the femoral neck with an almost complete anatomical comparison were performed. Next, osteosynthesis was performed with three cannulated screws with the creation of uniform compression in the fracture zone due to the successive tightening of the screws, intraoperative monitoring of the stability of osteosynthesis was carried out. Then, non-free plastic surgery of the femoral neck was performed with a blood-supplying bone autograft selected on a narrow (4 cm wide) muscular-vascular feeding leg from the front portion of the middle gluteus muscle, transplanted and fixed in the reconstruction area according to the developed technique (Figs. 7, 8).

The postoperative period was uneventful. 5 months after the operation, according to the results of the control examination and radiography, an enlargement of a fracture of the neck of the right femur with complete osseointegration of the transplanted bone autograft and good restoration of the function of the right hip joint was noted. The screws were removed 8 months after surgery (Fig.9, 10).

Claims (1)

A method for osteosynthesis of a femoral neck with non-free bone autoplasty, including open reposition and rigid stable fixation with compression of bone fragments by cannulated screws, as well as non-free plastic of the femoral neck with a blood-supplied autograft from the iliac crest, characterized in that the bone-transplanted muscle isotope transplant leg 4 cm wide, guaranteed to include an axial vascular bundle with a constant branch of the superior gluteal artery with a diameter of more 1 mm, which is extracted from the front portion of the middle gluteus muscle without distal cutting, then a non-free bone fragment is transplanted and placed in a prepared groove parallel to the axis of the femoral neck, and then the front end of the autograft is inserted into a preformed groove in the femoral head and additionally fix it with a screw.

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