RU2474398C1 - Method for shinbone extensive defect replacement - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely traumatology and orthopaedics, and may be used in surgical management of the patients with shinbone extensive defects of various aethiologies. At least double splint osteotomy is performed. From an external surface of the recovered proximal splint fragment, a longitudinal chip is formed. The formed fragments are gradually dislocated towards the shinbone defect zone; it is combined with ankle length and axis restoration. A proximal splint fragment is reduced to eliminate a head high position. The formed longitudinal chip of the proximal fragment is dislocated inwards to contact a side surface of the adjoining shinbone fragment. A compression-distraction apparatus is placed in a stable fixation mode to bone consolidation.

EFFECT: method provides more durable fusion of the shinbone fragments having a pathological structure, as well as promotes recovery of the anatomic contours of the proximal ankle, with improving a cosmetic effect.

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Description

The invention relates to medicine, in particular to orthopedics, and can be used in the treatment of patients with extensive defects of the tibia of various etiologies.

A known method of replacing a defect of the tibia by introducing transplantation material into the defect area (Yakunina L.N. Bone tissue transplantation with defects of tubular bones. - Chisinau: Shtiintsa, 1989. - 168 p.).

However, this method in the treatment of patients with extensive bone defects is associated with long periods of graft reconstruction and the possibility of its rejection.

A known method of replacing an extensive defect of the tibia, which involves performing a multilocal (multiple) osteotomy of the fibula and dosed introduction of the formed fragments into the area of the defect of the tibia with simultaneous restoration of the length and axis of the tibia using a compression-distraction apparatus (V.I.Shevtsov, V.D. . Makushin, KE Pozharishchensky. Treatment of patients with tibial defects with the method of reconstructive tibialization of the fibula. - Kurgan, "Periodic", 1994 - 256 S.).

However, when using this method, due to the broken bone structure and the small area of the fused surface of the tibia fragments, the initially achieved fusion strength is insufficient, which forces the patient to limit the load on the operated limb for a long time. In addition, the method does not provide for the restoration of the anatomical contours of the proximal leg, which reduces the cosmetic effect of the treatment.

The objective of the invention is to increase the strength of the fusion of fragments of the tibia and restoration of the contours of the proximal leg.

This problem is solved by the fact that in the method of replacing an extensive defect of the tibia, including performing a minimum of double osteotomy of the tibia and the metered displacement of its fragments into the defect of the tibia with simultaneous restoration of the length and axis of the tibia, as well as its stable fixation to the consolidation of the bone using compression -distraction apparatus, when performing an osteotomy of the fibula, from the inner surface of its selected proximal fragment, an additional prod ny and flake during its replacement defect displaced inwards into contact with the side surface of the adjacent fragment of the tibia, the fibula said fragment is reduced to eliminate high standing of the head.

The method is illustrated by a description, an example of practical use and illustrative material, which shows:

Figure 1 - radiographs of the lower leg of the patient before treatment;

Figure 2 - radiographs of the lower leg of the patient during the replacement of the defect;

Figure 3 - radiograph of the lower leg of the patient 1 year after treatment.

The method is as follows.

After anesthesia and treatment of the surgical field with known techniques, osteosynthesis of the affected segment is performed using a compression-distraction apparatus. When it is performed, fixing knitting needles are passed through the preserved proximal and distal fragments of the tibia, as well as through the fibula along its length. In this case, the proximal fragment of the tibia and the proximal end of the fibula are fixed separately. In a tense state, the spokes are mounted on the supporting elements - rings, arches - of the apparatus, using special fixators, as well as traction units mounted on movably connecting the proximal and distal supports of longitudinally arranged beams with threaded shanks. Along with this, if necessary, osteosynthesis of the distal third of the thigh and foot is performed by passing the spokes through the femur, heel, talus and metatarsal bones. These spokes are also mounted on supports installed in their projection, which are connected to each other and, with the help of hinges, to the system of the apparatus on the lower leg.

After completing the installation of the apparatus, through minimal cuts of soft tissues in the areas between the knitting needles, a minimum double osteotomy of the fibula is performed, forming its terminal - proximal and distal - fragments, the size of which should correspond to the size of adjacent fragments of the tibia. With significant curvature of the fibula, an osteotomy of its diaphysis is additionally performed, forming 2-3 intermediate fragments. Further, from the inner side surface of the selected proximal fragment of the fibula, a longitudinal flange is formed, which is fixed with needles with the possibility of lateral displacement in the direction of the adjacent fragment of the tibia.

To do this, the spokes drawn through it are mounted in traction units mounted on an external support.

The operation is completed by performing control radiography, suturing wounds and applying aseptic dressings, after which the apparatus systems are stabilized.

In the postoperative period, starting from 5-7 days, the selected intermediate fragment (or fragments) of the fibula is metered into the defect zone, and fragments of the tibia are bred together to restore the length of the tibia. In this case, the proximal fragment of the fibula is initially reduced to normalize the height of the head of the fibula, and the formed longitudinal flange of this fragment is shifted in width until it contacts the lateral surface of the proximal fragment of the tibia. The pace of movement varies between 0.5-1 mm per day.

Fragments in the defect are moved until it is completely replaced while the leg length and axis are normalized, after which the apparatus is put into stable fixation mode, which is maintained until bone consolidation. Additional immobilization of the limb after dismantling the apparatus, as a rule, is not required, the patient is prescribed a course of exercise therapy.

The practical use of the method is illustrated by the following clinical observation.

Patient G., 13 years old, was admitted to the clinic of the RRC "WTO" them. Acad. G.A. Ilizarova with a diagnosis of Hematogenous osteomyelitis, defect - diastasis of the right tibia 2 cm, shortening of the leg 14 cm (Fig. 1).

To restore the support ability of the limb, the length and axis of the lower leg, to eliminate the high standing of the head of the fibula, the patient underwent surgery: Osteosynthesis of the thigh, lower leg and foot using a compression-distraction apparatus, double osteotomy of the fibula, the formation of a longitudinal flake of its proximal fragment.

During the operation, after anesthesia and treatment of the surgical field, osteosynthesis of the affected limb was performed with holding spokes through the preserved proximal and distal fragments of the tibia, through the fibula over its length. In a tense state, the spokes were fixed on the external supports, as well as in the traction units located on the beams connecting the supports. The systems of the apparatus on the thigh and foot were pivotally connected to the apparatus on the shin.

Osteotomy of the fibula was performed through soft tissue incisions up to 1 cm in size, forming its end - proximal and distal - fragments, as well as an intermediate fragment of the diaphysis. At the same time, a longitudinal flange was formed from the inner lateral surface of the selected proximal fragment of the fibula, which was fixed with needles with the possibility of lateral displacement in the direction of the adjacent fragment of the tibia. The operation was completed by performing control radiography, suturing wounds and applying aseptic dressings, after which the apparatus systems were stabilized.

In the postoperative period, starting from day 7, the selected intermediate fragment of the fibula was metered into the defect zone, and fragments of the tibia were bred among themselves. In this case, the proximal fragment of the fibula was initially reduced to normalization of the standing height of the head of the fibula, and the formed longitudinal flange of this fragment was shifted in width to contact with the lateral surface of the proximal fragment of the tibia. The movement of fragments in the defect zone, the pace of which varied within 0.5-1.0 mm per day, was carried out until the axis and length of the leg were normalized (Fig. 2); the total duration of traction was 89 days, the period of subsequent stable fixation by the apparatus was 59 days. Additional limb immobilization after dismantling the apparatus was not performed, the patient underwent a course of exercise therapy.

As a result of treatment, due to the complete replacement of the defect of the tibia, the supportability of the right lower limb was restored, the length of the leg was increased by 14 cm.

At the follow-up examination after 1 year the achieved treatment result is saved, the patient walks without additional support means with a full load on the operated limb, whose axis is correct, movements in the knee joint: extension - 170 °, flexion - 80 °, in the ankle - ankylosis in functionally beneficial position (figure 3).

Using the proposed method showed that its use increases the strength of the fusion of fragments of the tibia with a pathological structure. This is facilitated by the formation in the fusion zone of the regenerate between the cleft and the proximal fragment of the fibula, which connects to the regenerate formed between the same and the nearest intermediate bone fragment, which leads to the creation of a vast area of newly formed bone tissue. At the same time, taking into account the normalization of the relative position of the head of the fibula and the adjacent fragment of the tibia, this helps to restore the contours of the proximal leg, thereby increasing the cosmetic result of treatment.

Claims (1)

A method for replacing an extensive defect of the tibia, including performing a minimum of double osteotomy of the tibia and dosed displacement of the formed fragments into the area of the defect of the tibia with simultaneous restoration of the length and axis of the tibia, as well as its stable fixation to the consolidation of the bone using a compression-distraction apparatus, characterized in that when performing an osteotomy of the fibula from the inner surface of its selected proximal fragment, additionally form longitudinal the flap and during the replacement of the defect it is displaced inside to contact with the lateral surface of the adjacent fragment of the tibia, while this fragment of the fibula is reduced to eliminate the high standing of its head.