RU2520800C1 - Method for surgical management of closed splinted tongue-shaped calcaneal fracture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves fragments reposition with using a reposition rod and bringing wires for cannulated screws. The reposition is followed by inserting at least two wires for temporary fragments fixation, while the reposition rod is removed. A biocomposite in the form of phosphate cement is introduced through its canal until a gap between the fragments is filled along a fracture line. After hardening, three wires are introduced to insert the cannulated screws. One wire is brought through the upper surface of a tongue-shaped fragment into an anterior calcaneal bone, while the other one - through the posterior fragment into the anterior calcaneal bone. The third pin is brought through the plantar surface of the posterior calcaneal bone into the anterior fragment. Thereafter, the cannulated screws with the diameter of 4.0 mm are introduced along the above wires, and then all the wires are removed.

EFFECT: more stable osteosynthesis involving no calcaneal bone shortening without a shear load of the screws.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of closed comminuted calcaneus fractures.

The most commonly used methods in the surgical treatment of calcaneus fractures are open reduction and plate osteosynthesis (IP Ardashev, VV Kalashnikov. “Traumatology and Orthopedics of Russia”, 4 (54), 2009, p.31-36). However, the use of these methods has limitations in patients with concomitant therapeutic pathology and is often complicated by regional wound necrosis, which is due to the peculiarity of access.

A known method of surgical treatment of comminuted fractures of the calcaneus, when the plate for bone osteosynthesis is installed after an open reposition. This implant, due to its size, causes considerable discomfort during the rehabilitation process and therefore must be removed after consolidation of the fracture (Zwipp H. - “Clin Orthop Relat Res.”: Osteosynthesis of displaced intraarticular fractures of the calcaneus, (290) p. 76-86) .

There is a method of treating closed “tongue-like” calcaneal fractures with bone fragments displacement, which is characterized by the use of reposition and the use of the Shants screw (Essex-Lopresti) followed by fixation with a plaster cast (M.E. Kupitman et al. Substantiation of a new method for closed reposition of calcaneal fractures bones. "Traumatology and Orthopedics of Russia", 2012, No. 4 (66), pp. 99-104). This design delivers significant inconvenience to the patient during treatment and rehabilitation.

Currently, most attention is paid to less traumatic minimally invasive treatments.

A method for the treatment of calcaneus fractures (RU 2463011, Barabash et al., July 19, 2011) is described, in which transosseous osteosynthesis is performed with an external fixation apparatus. Two crossed needles are carried through the middle and lower third of the lower leg. The spokes are fixed in the ring supports, which are interconnected by means of rods. A transosseous fixator in the form of a hook rod is introduced into the fragment of the calcaneus through the lower edge of the calcaneal tuber from the side of the plantar surface of the foot. The hook rod is fixed in the through hole of the support holder of the reposition unit. Spoke to protect the ankle joint from overextension during reposition through the front section of the talus bone, the needle is fixed in a semicircle. Dose reduction of fragments in the postoperative period is carried out. After achieving a complete reposition of the fragments, they are fixed by introducing into the calcaneus through the upper edge of the calcaneal tuber and the fracture line of the cannulated screws. The use of this method involves the use of a bulky design that worsens the quality of life of the patient during the rehabilitation period, and requires daily reposition in the early postoperative period.

There is a method of treating intra-articular impression calcaneus fractures using reposition and fixation of the fracture by cannulated screws (RU 2011125263, Dubinsky et al., 12/27/2012), the feature of which is its minimally invasiveness. Through an incision of up to 1.0 cm and a puncture of the skin, instrumental reposition of calcaneus fragments is performed under the control of electron-optical (EOP) imaging, secondly, through punctures of the skin, it is pulled together and fixed with a cannulated spongy compression screw with a diameter of 4.0 mm, fragments containing articular surfaces are pulled together and fix the fragments of the calcaneal tuber cannulated compression screws with triple thread diameters of 6.0 mm and 4.0 mm, in the end create an internal rigid calcaneus frame due to a birth canal through the entire calcaneus of the cannulated compression screw with a triple thread 6.0 mm in diameter: in the upper section, through the region of the subchondral layer of the posterior articular surface and in the lower section, parallel to the lower surface of the calcaneus, in case of fracture of the anterior calcaneus, guide needles are passed through the calcaneus cuboid joint and left until the fracture is consolidated, after which they are removed. The use of this method involves a second operation - the removal of metal fixators after a certain period of time, and the introduction of compression screws shortens the calcaneus.

There is a method of minimally invasive treatment of calcaneus fractures (RU 2440046, Bondarenko et al., January 20, 2012 - prototype), including reposition of the fracture with the help of a 6.5 mm screw rod or Shants screw. The rod is introduced from the calcaneal tuber side through the calcaneus to its anterior section in the direction of the plane parallel to the calvar-calcaneal joint, the fixation of the fragments is carried out by cannulated screws, carried out randomly in compression mode. This method is easy to use, however, when using large-diameter screws, a high degree of occurrence of fragment splitting, the risk of complications due to the pressure of the screw head on soft tissues; screw fixation in compression mode shortens the calcaneus, and arbitrary insertion of screws can lead to unstable fixation.

The authors set the task to develop a minimally invasive method of osteosynthesis for the treatment of closed comminuted calcaneus fractures.

The patented method includes reposition of fragments using a reposition rod and osteosynthesis using cannulated screws. At the same time, after reposition, at least two spokes are inserted for temporary fixation of the fragments, and the reposition rod is removed. Then, a biocomposite material is introduced through its channel until the gap between the fragments is filled along the fracture line, after the solidification of which three spokes are inserted to insert cannulated screws into the fracture fragments.

One spoke is passed through the upper surface of the “tongue-like” fragment into the front section of the calcaneus, the other through the back section of the “tongue-like” fragment into the front section of the calcaneus, and the third through the plantar surface of the posterior section of the calcaneus into the front section of the “tongue-shaped” fragment. After that, cannulated screws with a diameter of 4.0 mm are inserted through the mentioned knitting needles, and then all the knitting needles are removed.

The technical result achieved by the implementation of the patented method consists in the prevention of complications caused by the splitting of calcaneal bone fragments, as well as the exclusion of pressure of the screw head on soft tissues due to low-traumatic techniques for carrying out elements providing osteosynthesis; improving the functional results of treatment by maintaining the size of the calcaneus; increasing the reliability of fixation of fragments due to the choice of the trajectories of the introduction of fixing fragments of elements in a position of reliable reposition. Thus, the method provides increased stability of osteosynthesis without shortening the calcaneus in the absence of a shearing load of screws.

As a repositional rod, any known device can be used, for example, a Shants screw or a Steinman rod.

The invention is illustrated in the drawings, which shows the progress of the operation and a clinical example using a Shants screw:

figure 1 - lingual fracture of the calcaneus;

figure 2 - the introduction of the Shants screw into the calcaneal tubercle;

figure 3 - reposition of fragments screw Shants;

figure 4 - temporary fixation with needles;

figure 5 - the introduction of the biocomposite material along the channel from the screw Shants;

6 - holding spokes for cannulated screws;

Fig.7 - the introduction of cannulated screws on the knitting needles;

Fig.8 is the final result;

Fig.9, 10 - radiographs for a clinical example.

A method of treating closed comminuted calcaneus fractures (Fig. 1) is carried out using reposition and fixation of the fracture by holding screws through the tubercle and calcaneus body. A tongue-like fracture is characterized by the formation of two fragments 1, 2. The reposition is carried out by a 3-screw screw. The peculiarity of the reposition is that the Shants screw 3 is inserted through a skin incision (up to 1.5 cm) lateral to the Achilles tendon, the insertion point into the calcaneal tubercle is positioned as close as possible to the posterior articular facet of the calcaneus (Fig. 2). The reposition technique involves traction along the length - this restores the length of the calcaneus, after which the handle of the Shants screw 3 is moved in the direction 4, opposite to the displacement of fragments 1, 2: the back section of the “tongue-like” fragment is down, and the front fragment is up (Fig. 3 ) Then, bone fragments are temporarily fixed with at least two knitting needles 5, 6 (for example, Kirschner knitting needles) (Fig. 4), drawn through fragments 1, 2 of the fracture into the body of the talus 7, and the Shantz screw 3 is removed from the heel fragment. A biocomposite material 8 is introduced through a channel formed in the calcaneal tubercle as a result of the holding of the Shants screw 3 until the gap between the fragments 1, 2 is filled along the fracture line, for example, Synthes Chronos phosphate cement, which hardens for 5-7 minutes. This allows you to counteract the forces that displace the fragment in a vicious position - creates support from the bottom (figure 5). Then, under the control of the image intensifier, spokes 10-12 are inserted to insert cannulated screws. The cannulated screws 13-15 are inserted through the spokes, supporting the 1.2 fragments until the fracture is fused, and all the spokes are removed.

Fundamentally, the position of the cannulated screws d = 4.0 mm in the fracture fragments. The first spoke 10 is passed through the upper surface of the calcaneal tuber to the anterior section of the calcaneus (Fig. 6) - this spoke will neutralize the downward movement of the anterior fragment. The second spoke 11 is passed through the posterior section of the calcaneal tuber to the anterior calcaneus. The spoke 11 prevents upward displacement of the posterior calcaneus fragment. The third spoke 12 is passed through the plantar surface of the calcaneus, its posterior section, into the front section of the calcaneal tuber fragment. This spoke 12, based on a biocomposite material, prevents the lowering of the anterior portion of the heel fragment.

Clinical example. A sick man, 26 years old, was admitted with a diagnosis of closed fracture of the right calcaneus with an offset. During the operation, an incision was made less than 1 cm along the posterior surface of the right calcaneus and a Shants screw was inserted into the calcaneal tubercle. Fragments repaired. After reposition, two temporary spokes are introduced under the control of the image intensifier tube. Chronos phosphate cement was introduced along the channel from the Shants screw. Three guide knitting needles for cannulated screws were introduced: the first through the upper surface of the calcaneal tuber to the anterior section of the calcaneus, the second spoke through the posterior section of the calcaneal tuber to the anterior calcaneus, and the third through the plantar surface of the calcaneus, its posterior, into the anterior fragment of the calcaneal tuber. Then, three screws were introduced on the spokes. On the image intensifier tube, the correctness of the achieved reduction is confirmed. Stitches to the skin. In the postoperative period, the limb is immobilized with a plaster cast for four weeks, after which the plaster cast is replaced by a calcaneal orthosis with the possibility of reliance on the operated limb. Three months after the operation, the patient returned to his previous job. A good long-term result of treatment is confirmed by computed tomography data six and twelve months after the operation and high rates on the AOFAS rating scale.

This method of minimally invasive osteosynthesis made it possible to achieve a positive result in all operated patients with calcaneal bone fractures, improve the conditions for a complete and high-quality restoration of limb function, reduce the time of inpatient treatment and rehabilitation period, and reduce the risk of purulent-septic complications.

Claims (1)

A method for surgical treatment of closed comminuted tongue-like calcaneus fractures, comprising reposition of fragments using a reposition rod and osteosynthesis with knitting needles for insertion of cannulated screws through the fracture line,
characterized in that after reposition, at least two knitting needles are inserted for temporary fixation of the fragments, and the reposition rod is removed, then a biocomposite material in the form of phosphate cement is introduced through its channel until the gap between the fragments is filled along the fracture line, after which three knitting needles are inserted cannulated screws, while one spoke is passed through the upper surface of the tongue-like fragment into the anterior section of the calcaneus, the other through the posterior section of the said fragment into the anterior section of the fifth bone, and the third through the plantar surface of the posterior calcaneus into the anterior portion of the mentioned fragment, after which cannulated screws with a diameter of 4.0 mm are inserted through the said spokes, and then all the spokes are removed.

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