RU2534524C1 - Method for free osteoplasty of false joints of long bones - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: ends of both bone fragments are conically expanded throughout 2-3 cm by means of a chamber bit with cutting sides of a drill with an electric drill moving circularly. A procedure of cortical spongy autografting uses a double circular saw of the diameter of 5 cm and the disk distance of 1-1.8 cm, and a single circular saw of the diameter of 3.5 cm. A procedure of autografting involves creating two parallel lines of osteotomy by means of the double circular saw in the donor's segment; then the single circular saw is used to extend the ends of both lines of osteotomy on either side by 2.5-3.5 cm and to connect them to form a rhomb-shaped cortical spongy autograft with pointed ends. The pointed-end autograft is tightly penetrated into the conically expanded intramedullary canals of both bone fragments. The external fixation operation is completed by inserting the screws into a plate from the periphery to the centre so that the last screws shall be inserted through the middle engaging openings, except the bone fragments and rhomb-shaped autograft.

EFFECT: method increases the more stable fixation of the bone fragments.

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Description

The invention relates to medicine, namely to methods of bone grafting used in traumatology and orthopedics.

Despite the progress of operative orthopedics, the treatment of false joints of tubular bones remains an urgent problem of traumatology and orthopedics. The false joint is a diagnosis that excludes the hope of healing by conservative methods that only lengthen the already protracted treatment of fractures of the tubular bones. Along with stable osteosynthesis of bone fragments, the main goal of surgical treatment of the false joint is to freshen the ends of bone fragments with excision of the cartilage and scar tissue between them, removing the platelets and activating the suppressed reparative regeneration of bone tissue.

Analogs

There are various types of surgical interventions aimed at activating osteogenesis in the treatment of pseudoarthrosis, the most famous of which are Beck osteoperforation (Fig. 1, a), osteoplasty with a sliding autograft according to Khakhutov (Fig. 1, b) and bone grafting intra- and extramedullary transplants according to Chaklin (figure 1, c).

Criticism of analogues

The simplest of the analogues is Beck osteoperforation (Fig. 1, a), however, due to the lack of effectiveness, it is practically not used for pseudarthrosis, since it is limited only to the deployment of sclerotic ends of bone fragments. The low efficiency of this manipulation is also due to the leaving of cartilage and scar tissue between the fragments, the relative randomness of drilling bones from two or three points with the inevitability of bone destruction and the lack of the ability to accurately control the direction of drilling of the channels.

Many types of bone grafting are known for replacement, support, and osteoinductive purposes, the most common of which are homoplasty with a preserved demineralized allograft and autoplasty with a cortical-spongy graft taken from the patient himself. In case of autoplasty using a sliding graft according to Khakhutov (Fig. 1, b), after exposure of the pseudoarthrosis zone and skeletonization of bone fragments at a sufficient length for autograft grafting, a circular electric saw or a Jigley wire saw cut the bone longitudinally through the zone of the false joint to the desired distance. In this case, two longitudinal autografts of equal width but different lengths are obtained: usually the length of one of them is twice the length of the other. Then they are interchanged and the larger of the autografts overlaps the pseudoarthrosis zone. Both autografts are fixed to the bed with catgut ligatures or wire cerclage and, as a rule, supplemented with osteosynthesis with a plate with screws or an external fixation device. The disadvantages of this type of autoplasty are the following:

- a relatively large length of skeletonization of bone fragments with a decrease in blood supply and inhibition of osteogenic potentials of bone fragments;

- weakening of the strength of bone fragments during their sawing, especially with atrophic false joints and osteoporosis of bone fragments;

- high requirements for the precision accuracy of the operation technique with its inefficiency in the case of frequent cracking or incongruence of autograft strips, since the sawn (and weakened!) ends of bone fragments are usually no longer suitable for fixing something or using another method of osteoplasty.

Prototype

As a prototype method, osteoplasty with bone and intraosseous grafts according to Chaklin (Fig. 1, c) described in the National Guide to Traumatology (National Guide to Traumatology under the editorship of GP Kotelnikov, SP Mironov. - M: - M: GEO-TAR-Media, 2008, - 808 p., S. 312-314). This method of bone grafting consists in the use of intraosseous and bone grafts, the first being an allograft (canned bone), and the second is an autograft. The allograft in diameter and shape must correspond to the bone marrow channel of the associated bone fragments, into which it is tightly implanted with a mechanical and osteoinductive target. A bone autograft, usually taken from the proximal tibia metadiaphysis, is placed on top of the matched bone fragments and fixed with cerclage, catgut or lavsan ligatures carried out around the bone using the Fedorov clamp or Deschan's needle.

Prototype criticism

Osteoplasty with intra- and extramedullary grafts according to Chaklin has the following disadvantages:

- the compulsion to increase the volume and morbidity of the operation - with a wide skeletonization of bone fragments, accompanied by a deterioration in their blood supply and delaying the formation of bone callus;

- the need for a sufficient amount of bone substance: auto- and allo grafts. So, the use of an allograft is associated with the need to search for it (the presence of a bone bank with expensive technological preservation of cadaveric bone);

- antigenic properties of foreign bone tissue when using an allograft;

- the risk of rejection of the allograft and the addition of purulent complications;

- dense clogging of the bone marrow cavity with an intramedullary graft, which is associated with inhibition of endosteal reparative osteogenesis;

- the use of a bone autograft placed and fixed on top of matching bone fragments significantly changes the contour of the bone, which limits the acceptability range of some types of osteosynthesis, for example, bone osteosynthesis with screw plates. This inevitably leads to a decrease in the quality of osteosynthesis and the limitation of its capabilities and, accordingly, delays the time and reduces the effectiveness of the treatment of false joints.

The purpose of the invention is to increase the effectiveness of the treatment of patients with false joints of tubular bones.

SUMMARY OF THE INVENTION

A method of free bone grafting of false joints of tubular bones is proposed, which consists in the following. Perform a longitudinal skin incision of the desired length and layer by layer reach the area of the false joint of the tubular bone (Fig.2, a). Bone fragments are economically isolated, and their ends are treated with a raspator, drills and a countersink (Fig. 2, b). In this case, bone fragments are sequentially brought into the wound, cartilage and scar tissue preventing them from forming bone marrow are excised, the closure plates are removed, and the patency of the obliterated bone marrow canals is restored. After that, the ends of the bone fragments are cone-shaped to expand the ends of the bone fragments by a cone cutter or countersink (if there is no countersink, then the ends of the bone fragments can be countersinked by the lateral cutting edges of the drill during circular movements of the electric drill) - preferably until “blood dew” appears on the treated bone surface. Thus, a cone-shaped expansion of the medullary canal is formed at the ends of bone fragments (Fig. 2, c). Then cover the wound with a sterile gauze moistened with saline and start the operation of taking a cortical-spongy autograft. To improve the quality of this manipulation and to prevent cracking of the graft and the donor bed with the osteotomy line going beyond the intended range, an autograft is taken as follows. A double circular saw with a diameter of 5 cm with a distance between its disks of 1-1.8 cm is used, depending on the maximum diameter of the cone-shaped enlarged bone marrow canal of both bone fragments. Having formed on the donor site of the bone (usually the proximal metaphysis of the tibia) with a double circular saw two parallel lines of osteotomy of the desired length (Fig. 3, a), disconnect the double circular saw from the drill and install a single saw with a diameter of 3.5 cm. Then, with a single saw, the ends of both osteotomy lines continue on both sides by 2.5-3.5 cm (Fig. 3, b) and connect them together with the same saw (Fig. 3, c) to form a diamond-shaped cortical-spongy autograft with pointed ends. This autograft is extracted with a chisel from a donor bone bed. The periosteum over the donor bone bed is restored with interrupted sutures, and the wound is sutured in layers. The resulting autograft is adjusted in length and width to the bone marrow channel of the bone fragments and tightly implanted with one of the two pointed ends into one (usually the larger) of the two bone fragments (Fig. 4, a). Moreover, for a denser autograft landing, the largest internal diameter of the bone marrow canal of bone fragments is 1-2 mm smaller than the diameter of the widest part of the autograft. If the diameter of the medullary canal is equal to or slightly larger than the diameter of the widest part of the autograft, then on the lateral faces of the latter with a circular saw, several shallow (1-2 mm) notches can be made as corrugations that increase the transplant surface and the adhesion between it and the medullary canal. Then, another bone fragment should be strung on the pointed end of the autograft, protruding from the bone marrow channel of the first bone fragment (Fig. 4, b), for which you need to grab the second bone fragment with sequestral forceps, pull it and tilt it a little. If this technique is not enough, then a groove (“chink”) is formed on the edge of the second bone fragment by the lateral cutting edges of the drill on an electric drill, through which the pointed end of the autograft is inserted into the medullary canal. With a tight fit and jamming of the autograft in the medullary canal, reposition and immobilization of bone fragments is achieved. If the false joint is accompanied by resorption of the ends of bone fragments and shortening of the bone, then shortening can be compensated by increasing the length of the diamond-shaped autograft. The oblong (or rectangular) shape of the autograft when it is jammed in the medullary canal ensures rotational stability of bone fragments and incomplete closure of the lumen of the medullary canal, which is essential for the optimal course of endostal reparative osteogenesis. If the operation is completed, then after layer-by-layer suturing of the wound, a plaster cast is applied, which, after healing of the wound and removal of the sutures, is transferred to a circular plaster cast. However, for reliable stabilization of bone fragments and early restoration of movements in adjacent joints of the limb, osteosynthesis should be performed - bone or extra focal. When performing plate osteosynthesis with a plate on screws, the procedure for introducing screws matters. So, to enhance compression at the junction of bone fragments with the rational use of elongated holes in the plate, screws must be inserted from the periphery to the center of the plate. In this case, the screws are inserted last through the middle holes of the plate, because these screws capture, in addition to bone fragments, the autograft, thereby enhancing the stability of fixation of the fragments and autograft.

An example of the method

As an example of the application of the proposed method for free bone grafting of false joints of tubular bones, we give the following observation.

Patient M., born in 1949 (63 years old), was admitted to the Republican Orthopedic Traumatology Center (ROTC) 02/02/13 with a diagnosis of False joint of both bones of the lower third of the right forearm with displacement of fragments.

From the anamnesis: more than 7 months ago (at the end of May last year) after a household injury, a closed fracture of both bones of the right forearm — the radius in the lower third and the ulna at the border of the middle and lower third — occurred. She was treated in the trauma department of the Kizilyurt Central City Hospital, where an operation of intramedullary ulnar osteosynthesis with two Kirschner spokes was performed. The fracture did not heal, the spokes were removed.

Upon admission to the RTC, the general condition of the patient is satisfactory. There is obesity of the II degree. Locally, there is a relative shortening of the right upper limb by 1.0 cm due to the forearm segment, swelling of the middle and lower third of the forearm with pathological mobility, crepitus and palpation of tenderness in the diaphysis of the ulnar and distal ends of the radius. On the medial surface of the lower third of the forearm there is a scar from the initially healed postoperative wound. There are no neurotrophic and vascular disorders of the upper limb.

On radiographs of the right forearm in two projections from 02/02/13, there is a false joint of the lower third of both bones of the right forearm with displacement of bone fragments (Fig. 5, a, b).

In the planned order on 02/13/13, the operation was performed: Autoplasty of the false joint of both bones of the lower third of the right forearm and osteosynthesis with a plate with Kirchner screws and knitting needles.

Under conduction anesthesia of the brachial plexus, a longitudinal skin incision was made along the old postoperative scar, about 10 cm long. Bone fragments of the ulna were exposed and skeletal, the atrophic ends of which were freed from scar tissue, refreshed and processed with a drill and countersink to remove the locking plates, restore patency and conical expansion of the medullary canal.

In the area of the proximal metaphysis of the tibia, a double circular saw with a diameter of 5 cm and a distance between its disks of 1.0 cm and a single saw with a diameter of 3.5 cm took a subperiosteal strip of a diamond-shaped free cortical-spongy autograft 6-7 cm long, 1 cm wide and 0.6-0.7 cm thick. The graft is sawn into two parts with the formation of double-edged diamond-shaped wedges for use on both bones of the forearm. The periosteum is laid and sutured over the resulting oblong tibial metaphysis defect, and the donor wound is sutured in layers.

One of the two wedge-shaped autografts is tightly embedded in both cone-shaped elbows, and to increase the wedging effect, its width was slightly greater (1-2 mm) than the diameter of the prepared bed. This was due to the fact that with the tight introduction of the autograft there is a better "grinding" (mutual adaptation) of it with bone fragments. Then, bone osteosynthesis was performed with a 10.5-centimeter plate with 6 oval holes on 6 4.5 mm screws with a length of 1.8 to 2.5 cm with increased compression between the bone fragments, with the latter introduced 2 middle screws. The wound is sutured in layers.

A 5–6 cm long skin incision was made along the posterior-outer side of the lower third of the forearm. The fascia was dissected and the incision continued along the muscle extensor with a sharp and blunt path between the common extensor of the fingers and the radial short extensor of the hand. The area of the false joint of the lower third of the radial bone was visualized. The ends of the bone fragments are cleaned, reposition is performed, and with correction of deformation, a wedge-shaped autograft is introduced into the gap formed between the bone fragments. From the side of the styloid process of the radius through the two bone fragments and the sphenoid autograft, two Kirschner spokes are slanted longitudinally. The wound is sutured in layers. A plaster cast was applied from the middle third of the shoulder to the fingers. On the control radiographs, a satisfactory position of the bone fragments was verified (Fig.6, a, b).

The postoperative period was uneventful, the wound healed first, the sutures were removed on the 8th day. The plaster cast was transferred to a circular plaster cast, and the patient was discharged for outpatient treatment with the recommendation to remove the plaster immobilization and remove the Kirchner knitting needles after 1.5 months. The result of the treatment is regarded as good.

Features of the invention, distinctive from the prototype

Distinctive features of the prototype of the proposed method of free bone grafting of false joints of tubular bones are:

- the implementation of a cone-shaped extension of the ends of both bone fragments for 2-3 cm with a countersink or countersinking by the side cutting edges of the drill during circular movements of the electric drill;

- use when taking a cortical-spongy autograft of a double circular saw with a diameter of 5 cm and a distance between its disks of 1-1.8 cm and a single circular saw with a diameter of 3.5 cm;

- upon receipt of an autograft with a double circular saw, two parallel osteotomy lines are formed on the donor site of the bone, then the ends of both osteotomy lines are continued to both sides by 2.5-3.5 cm with a single saw and connected to form a diamond-shaped cortical-spongy autograft with the pointed ends that are removed from the bed with a chisel;

- the correspondence of the pointed ends of the rhomboid cortical-spongy autograft and the cone-shaped ends of the bone fragments;

- the pointed ends of the rhomboid cortical-spongy autograft provide its jamming in the medullary canal of bone fragments;

- the autograft with pointed ends is tightly inserted into the cone-shaped bone marrow channels of both bone fragments;

- for a denser landing of the autograft, the largest internal diameter of the bone marrow canal of bone fragments is 1-2 mm less than the diameter of the widest part of the autograft;

- if the diameter of the medullary canal is equal to or even slightly larger than the diameter of the widest part of the autograft, several notches are applied on the lateral faces of the latter with a circular saw as a corrugation that increases the surface of the graft and the adhesion between it and the medullary canal;

- in order to string a second bone fragment on the pointed end of the autograft protruding from the first bone fragment, you need to grab the second bone fragment with sequestral forceps, pull it off and slightly tilt it. If this technique is not enough, then a groove (“chink”) is formed on the edge of the second bone fragment by the lateral cutting faces of the drill on an electric drill, through which the pointed end of the autograft is inserted into the medullary canal;

- the oblong (or rectangular) shape of the autograft when it is jammed in the medullary canal ensures rotational stability of bone fragments and incomplete closure of the lumen of the medullary canal;

- at the end of the operation with bone osteosynthesis, the sequence of introducing screws into the plate is important, namely, from the periphery to the center, so that the screws are inserted through the middle holes with capture, except bone fragments and a diamond-shaped autograft.

The technical result (advantages over the prototype) of the method of free bone grafting of false joints of tubular bones:

- precision accuracy of taking a cortical-spongy autograft with the exception of cracking and the osteotomy line beyond the intended range;

- minimizing the mechanical weakening of the donor site;

- the pointed ends of the rhomboid cortical-spongy autograft provide its reliable jamming in the medullary canal of both bone fragments;

- the correspondence of the pointed ends of the rhomboid cortical-spongy autograft and the cone-shaped ends of the bone fragments provides the maximum contact area between the autograft and the perceiving bone bed of bone fragments;

- if there is a shortening of the bone to compensate, you can increase the length of the diamond-shaped autograft;

- to increase the coupling between the autograft and the bone marrow canal, on the lateral sides of the autograft with a circular saw, several notches can be applied as a corrugation, which is shown when the diameter of the bone marrow canal exceeds the width of the autograft;

- tight contact between bone fragments and autograft, in addition to primary stability and mechanical stability of fixation of bone fragments, provides optimal biological conditions for the reparative regeneration of bone tissue and the speediest fusion of the false joint;

- to enhance the stability of fixation of the autograft stuck in the bone marrow canal of bone fragments, when performing bone marrow osteosynthesis, the screws are inserted from the periphery to the center, introducing the last screws through the middle holes of the plate and capturing them, in addition to bone fragments, and the autograft;

- the oblong (or rectangular) shape of the autograft when it is jammed in the medullary canal ensures rotational stability of the bone fragments and incomplete closure of the lumen of the medullary canal, which is essential for the optimal course of endostatic reparative osteogenesis;

- the cost-effectiveness of the autoplasty method with the absence of the need to search for material (bone tissue) for the false joint plastic;

- the exclusion of an antigenic reaction to an autograft and related complications.

Thus, the proposed method of bone grafting can increase the effectiveness of the treatment of patients with false joints of tubular bones.

Literature

1) Boychev B., Conforti B., Chokanov K. Operative orthopedics and traumatology. - 2nd ed., Revised. and add. - DI "Medicine and physical education", - Sofia, 1958 - 832 p. - S. 94-101;

2) Movshovich I.A. Operative orthopedics: (Manual for doctors). - 2nd ed., Revised. and add. - M .: Medicine, 1994 - 448 p. - S. 31-35.

3) Brusko A.T. Biomechanical conditions for the activation of osteogenesis // Orthopedist., Injuries. and prosthetics. - 1994 - No. 2. - S. 16-21.

4) Korzh N.A., Kladchenko L.A., Malyshkina S.V., Timchenko I.B. Implant materials and osteogenesis. The role of biological fixation and osseointegration in bone reconstruction // Orthopedist. injury - 2005. - No. 4. - S. 118-127.

5) Ostroverkhov G.E., Bomash Yu.M., Lubotsky D.N. Operative surgery and topographic anatomy. - The fifth edition. - M .: Medical Information Agency LLC, 2005 - 736 p. - S. 224-225.

6) Traumatology: national leadership / ed. G.P. Kotelnikova, S.P. Mironova. - M.: GEOTAR-Media, 2008 - 808 p. - (Series "National Guides"), S. 312-314 - prototype device.

Claims (1)

A method of free bone grafting of false joints of long tubular bones with a cortical-spongy autograft taken from the upper metaphysis of the tibia, characterized in that they perform a cone-shaped extension of the ends of both bone fragments for 2-3 cm with a countersink by the side cutting edges of the drill during circular movements of the electric drill; when taking a cortical-spongy autograft, use a double circular saw with a diameter of 5 cm and a distance between its disks of 1-1.8 cm and a single circular saw with a diameter of 3.5 cm; when receiving an autograft with a double circular saw, two parallel osteotomy lines are formed on the donor site of the bone, then the ends of both osteotomy lines continue to be 2.5-3.5 cm on both sides with a single saw and connect them to form a diamond-shaped cortical-spongy autograft with pointed ends that are removed from the bed with a chisel; ensure the correspondence of the pointed ends of the rhomboid cortical-spongy autograft and the cone-shaped ends of the bone fragments; the autograft with pointed ends is tightly inserted into the cone-shaped bone marrow channels of both bone fragments; for a denser autograft landing, the largest internal diameter of the bone marrow canal of bone fragments is 1-2 mm less than the diameter of the widest part of the autograft; at the end of the operation with bone osteosynthesis, the screws are inserted into the plate from the periphery to the center, so that the screws are inserted through the middle holes with the capture, except for bone fragments and a diamond-shaped autograft.

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