RU2533017C1 - Method of treating ganglia of long bones - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: at 1.5-3 cm from a cyst envelope along the long axis of the bone along its anterior outer surface, a cortical layer of the bone is perforated to drill out an intramedullary canal to reach the cyst left unexposed, and a canal is created. An elastic curved tube with a flexible mandrel inside is inserted through the created perforation along the formed canal, and one of the tube ends is inserted inside the cyst cavity, herewith exposing the soft tissue, osseous septums and lepidic tissues of the cyst with using the flexible mandrel. The flexible mandrel is removed, and the cavity is washed with normal saline through the tube to visualise the absence of impurities in the wash liquid. The cavity is treated through the tube, and the bone tissue content is drained off with the cyst treated with 2-3% chymotrypsin. The bone defect is repaired with a bone plastic material through the tube. The surgical intervention is completed by performing the intramedullary osteosynthesis of the bone.

EFFECT: method provides reducing injuries and a risk of recurrence.

3 cl, 1 ex

Description

The invention relates to medicine, namely to orthopedics, and can be used in the treatment of cystic formations of long tubular bones.

Known methods for treating bone cysts, including the removal of the contents of cystic bone formations and treatment of the freed cavity through various factors, in particular:

- the impact on the pathology of the microwave electromagnetic field in the destruction mode [RU patent for the invention No. 2230510];

- performing the emptying of the cystic cavity by actively aspirating with a syringe through an installed needle and treating the cyst cavity first with a hemostatic preparation and then with laser radiation [RU patent for invention No. 2217088];

- puncturing with a trocar with a cyst needle in its upper and lower third, followed by continuous flow drainage of the cyst cavity with drugs, including fibrinolysis inhibitors, protease inhibitors, steroid hormones, protein denaturators, and the introduction of venous blood into the cyst cavity with “flour” of a demineralized matrix [ RU patent for the invention No. 2069995].

However, when a microwave exposure to a bone occurs in a destruction mode, the pathological lesion is destroyed, but the cause of its appearance, disturbance of the venous drainage in the metaphysical part of the bone, is not eliminated, and the resulting necrotic area of the bone subsequently negatively affects the regeneration process.

In a method that involves treating a cyst cavity with laser radiation, no plastic bone defect is produced after emptying the cyst cavity. The disadvantage of this method is the significant period of gypsum immobilization - 2-3 weeks, which does not allow patients to give an early load on the operated limb with the earliest possible activation.

The disadvantage of the method described in patent No. 2069995 is the lack of control over the state of the regenerative process, as well as the discrete nature of the effect. Prolonged drainage of the cyst cavity can cause infectious complications.

Bone cysts result from blood supply dysfunction - inflow and outflow. An increase in blood flow leads to an increase in intraosseous pressure, and under-oxidized waste products alter the pH, which, in turn, leads to the lysis of bone substance. The mechanical way to remove the contents of the bone cyst and the replacement of the cavity does not eliminate the pathogenic links of the pathology. The solution to this problem requires equalization of intraosseous blood supply, which accounts for ¾ of the total volume of blood entering the bone cavity.

Known methods of treating bone cysts aimed at improving blood circulation [RU patents for inventions No. 216060 and No. 216001 of the same patent holder].

In the method described in patent RU No. 2160060, the affected segment is fixed by the transosseous device with the formation of a musculoskeletal flap on a healthy area of the bone with its metered movement to the affected area using a spoke with a support pad fixed to the external supports of the transosseous device. The flap is performed on a nourishing muscular leg of a pointed shape, the apex of which is directed to the pathological focus. After fixing the flap with a knitting needle with a support platform, it is carried out through the pathological focus with simultaneous longitudinal rotation.

In the method described in patent RU No. 2160061, a bone cyst is punctured and its contents are removed. The cavity is washed and drugs are injected into it. Additionally, the periosteum is peeled off around the perimeter of the bone through a minimal skin incision proximal and / or distal to the cyst zone.

However, indications for the operation of the method described in patent No. 216606 are strictly limited and are not universal. The treatment of patients is long and associated with transosseous fixation. All this is burdensome for patients. Complications of the purulent nature of soft tissues in transosseous elements reach 17%.

In the method that describes the puncture of a bone cyst with the removal of its contents - Patent No. 2160061, prolonged drainage of the cyst cavity can cause an infectious complication, and repeated puncture is very traumatic for the patient and prolongs the healing process. The disadvantage of this method is the prolonged immobilization of the operated limb. The load on the limb is possible no earlier than after 3 months.

The closest analogue to the claimed invention is a method for the treatment of tumor-like diseases [Our experience with the use of CollapAn in the treatment of benign bone tumors / V.I. Zorya [et al.] // Collection of works of the All-Russian Scientific and Practical Conference “The Use of Artificial Calcium-Phosphate Biomaterials in Traumatology and Orthopedics”. Moscow. 2010. S.22-23]. It is characterized by the fact that the bone defect is plasticized with an allograft of the brushwood type, the chymotrypsin is filled in a maximum dose of 40 mg, and the remaining interplant grafts are carefully filled with CollapAn. Crystalline chymotrypsin present in the wound breaks down necrotic tissues with the release of mediators of cell proliferation, helps increase blood flow and activate metabolic processes in bone regenerate, accelerates the reconstruction of plastic material and the restoration of full bone.

However, this method implies a classical edge resection of a pathological bone lesion followed by plastic surgery of a post-resection defect with an allograft.

The task of the invention is to simplify the process of surgical intervention while reducing the time it takes and reducing its morbidity, as well as significantly reducing the risk of recurrence of the pathological process.

The essence of the claimed invention lies in the fact that in a method of treating cystic formations of long tubular bones, comprising treating a cyst cavity with chymotrypsin and performing plastic surgery of a bone defect with bone-plastic material, fibrinolysis inhibitors are administered intravenously before the main stage of the surgical intervention, then extrafocally, at a distance of 1, 5-3 cm from the shell of the cyst along the longitudinal axis of the bone along its front outer surface, make a hole in the cortical layer of the bone through which produce reaming of the medullary canal to the cyst without opening it with the formation of the canal; through the formed hole through the formed channel, an elastic curved tube with a flexible mandrain is inserted inside it and one of the ends of the tube is drawn inside the cyst cavity, while opening with the help of a flexible mandrel soft tissue formations, bone partitions of the cyst and its lining; the flexible mandrin is removed and the cavity is flushed through the tube with physiological saline to visualize the absence of impurities in the wash liquid; after the cavity is processed through the tube and the contents of the bone cyst are aspirated; moreover, the treatment of the cavity of the cyst is performed with a 2-3% solution of chymotrypsin; bone defect plasty with bone-plastic material is performed through a tube; complete the surgery by performing intramedullary bone osteosynthesis.

A method is also claimed with the above-described features, in which intramedullary osteosynthesis is performed with one or two elasto-flexible rods of the TENO type (titanium elastic nails). With intramedullary osteosynthesis, one rod is inserted into the medullary canal from the opposite side of the eccentrically located cyst.

The technical result of the claimed invention

The implementation of all the main manipulations during surgery through a curved tube inserted into the bone marrow canal of the damaged bone through an opening formed in its cortical layer, performed outside the pathology zone, allows to simplify the process of the proposed method, significantly reducing the time of its carrying out and reducing the morbidity. All of the above advantages contribute to reducing the rehabilitation period, providing early activation of the patient and minimizing the possibility of postoperative complications.

Dissection of the cyst cavity using a tube and removal of the cyst contents by remote drainage through it allows you to equalize the difference in intraosseous pressure, thereby eliminating the pathogenic links of the pathology, eliminating the possibility of relapse. Performing a washing of the cyst cavity with a solution of chymotrypsin leads to the breakdown of proteins of fibrous formation and the “blocking" of under-oxidized products, which helps to prevent recurrence of the pathological process.

Performing intramedullary osteosynthesis allows you to equalize the bone marrow pressure throughout the bone and is the prevention of pathological fractures.

A method of treating cystic formations of long tubular bones is as follows.

They lay the patient lying on his back, with an orientation depending on the location of the pathology according to radiographs. Surgical intervention is performed under general anesthesia. In order to prevent bleeding, fibrinolysis inhibitors, in particular, 5% aminocaproic acid in isotonic solution in a volume of up to 100 ml, are injected intravenously to a patient in a droplet rate of 50-60 drops per minute.

Process the surgical field. Depending on the location of the pathology, through an incision of the order of 3 cm distal or proximal to the pathology zone at a distance of 1.5-3 cm from the cyst along the longitudinal axis of the bone along its front external surface under the control of the electron-optical transducer, a hole in the cortical is made using a drill and drill a layer of bone through which the bone marrow canal is drilled to the cyst without opening it with the formation of the canal. Through the formed hole and the formed channel, an elastic curved tube with a flexible mandrel is inserted with the possibility of opening through the last soft tissue formations, the bony septum of the cyst and its lining and passing one of the ends of the tube into the cyst cavity. While maintaining the mechanical strength of the cortical layers in the projection of the cyst, the tube is bent at an angle of 85-90 °, with significant thinning of the cortical layers in the projection of the cyst, at an angle of 45-60 °. Mandren is removed. The cystic cavity is washed through the tube with a syringe with physiological saline 0.9% NaCl until the absence of impurities in the wash fluid is visualized. Then the cyst cavity is washed with a 2-3% solution of chymotrypsin in a volume of 20 mg per 20 ml of physiological solution of 0.9% NaCl. After the external end of the tube, located outside the wound, is connected to a vacuum suction and the contents of the bone cyst are sucked off with a vacuum extractor. Next, plastic bone defect is performed along the tube with bone-plastic material. The wound is sutured tightly. Through a separate surgical approach, away from the cyst, closed intramedullary osteosynthesis is performed with one or two TENO elastic flexible rods, depending on the affected segment — the thigh, shoulder, forearm, lower leg. In osteosynthesis with a single rod, the side of its introduction into the bone is always opposite to an eccentrically located cyst.

After complete reconstruction of the osteoplastic material and restoration of the anatomical shape and structure of the bone, the rods are removed.

Example

Patient P., 15 years old, was admitted to the clinical department with a diagnosis of "Aneurysmal cyst of the upper third of the right tibia."

According to x-rays, it was noted that the eccentrically located lytic focus of the bone marrow cavity of the metaphysis occupies ½ of the diameter of the tibia.

After preoperative preparation, the patient underwent surgery according to the method described in this invention under the control of an electron-optical converter. A hole for introducing an elastic tube was formed in the proximal tibia along its outer surface at a distance of 3 cm from the cyst membrane. Bone defect plasty was performed using a MIIG-115 synthetic allograft. A closed intramedullary osteosynthesis with a titanium rod was performed using the TENO technology (titanium elastic nails). For this, the bone marrow canal was opened. The rotary movements introduced the awl at an angle of 45 ° to the axis of the bone. A truncated impactor and light hammer blows introduced a rod from the proximal side of the bone, i.e. opposite eccentrically located cyst.

In the postoperative period, from the 5th day after surgery after the pain subsided, classes of therapeutic exercises and early activation with a partial load on the limb were carried out.

On the 14th day after the surgical intervention, the sutures were removed and the patient was discharged for outpatient treatment at the place of residence. Additional immobilization for neither the upper nor the lower extremities was required. Outpatient rehabilitation continued with the earliest possible inclusion of motor and axial loads on the operated limb.

During the follow-up examination 3 months after surgery, the patient performed a full load on the limb, no complaints. On the roentgenogram noted: complete restructuring of the allograft, restoration of the anatomical shape and structure of the bone.

Claims (3)

1. A method of treating cystic formations of long tubular bones, comprising treating the cyst cavity with chymotrypsin and performing plastic surgery of the bone defect with bone-plastic material, characterized in that fibrinolysis inhibitors are administered intravenously before the main stage of the surgical intervention, then extrafocally, at a distance of 1.5-3 cm from the cyst membrane along the longitudinal axis of the bone along its front outer surface, a hole is made in the cortical layer of the bone through which the bone marrow is drilled ala to cysts without its opening to form a channel; through the formed hole through the formed channel, an elastic curved tube with a flexible mandrain is inserted inside it and one of the ends of the tube is drawn inside the cyst cavity, while opening with the help of a flexible mandrel soft tissue formations, bone partitions of the cyst and its lining; the flexible mandrin is removed and the cavity is flushed through the tube with physiological saline to visualize the absence of impurities in the wash liquid; after the cavity is processed through the tube and the contents of the bone cyst are aspirated; moreover, the treatment of the cavity of the cyst is performed with a 2-3% solution of chymotrypsin; plastic bone defect bone-plastic material is performed on the tube; complete the surgery by performing intramedullary bone osteosynthesis. 2. The method according to claim 1, characterized in that the intramedullary osteosynthesis is performed by one or two elasto-flexible rods of the TENO type (titanium elastic nails). 3. The method according to claim 2, characterized in that when performing intramedullary osteosynthesis with one rod, it is inserted into the bone marrow canal of the bone from the opposite side of the eccentrically located cyst.