RU2537067C1 - Method of treating tibial intercondyloid eminence fracture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: arthroscope-assisted anatomic setting of a fracture is combined with a temporal percutaneous Kirschner wire fixation through a proximal tibial metaphysis. The injured extremity is bent in a knee joint at an angle of 90-100 degrees. The 0.4-0.5cm skin incision in the position of two o'clock is performed along a medial edge of an upper pole of a patella. The joint capsule is approached by a layered, blunt and sharp technique, and the 0.2-0.3cm capsular incision is performed in parallel to a patellar edge. A guide pin of the diameter of 1.5mm is inserted through the formed medial port into the joint cavity on the periphery of fossa intercondylaris, not contacting the joint surface in a plane parallel to the tibial axis towards the intercondyloid eminence. A guide wire is inserted along the guide pin into the joint cavity through the medial port. The pin is removed. A bone canal is drilled out along the guide wire in the proximal tibial metaphysis in accordance to the implant diameter. An osteosynthesis of the tibial intercondyloid eminence fracture is performed with the use of the biodegradable implant through the guide wire along the formed canal. The fixation pin delivered through the proximal tibial metaphysis is removed. A plaster immobilisation follows.

EFFECT: method enables reducing injuries, and increasing fixation stability.

1 ex, 8 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used to treat fractures of the intercondylar elevation of the tibia.

A closed fracture of the intercondylar elevation of the tibia is a typical tear fracture, more characteristic of childhood, corresponds to a rupture of the anterior cruciate ligament in adult patients. The fracture line passes through the proximal pineal gland, while a significant part of the upper articular surface is completely or partially torn off from the bone - an intra-articular fracture of the intercondylar elevation of the tibia, and sometimes the torn bone-cartilaginous part is fragmented - this is the so-called fragmentary fracture. By type, such fractures are divided into: a fracture without displacement, a fracture with a slight displacement, a complete separation, comminuted or rotated fracture. The main way to treat bone fractures in children, regardless of age and localization, is still considered conservative management. Indications for conservative tactics are fractures without displacement and satisfactory standing of the fragments on the control radiographs after gypsum immobilization in the overreposition position.

There is a method of conservative treatment of a fracture of the anterior intercondylar elevation of the tibia, including complete extension of the tibia in the knee joint and fixation for the period of fracture fusion, for which the tibia is preliminarily bent at the knee joint at an angle of 30-40 °, it is retracted outward, anteriorly shifted, and internal rotation to the border of elastic resistance, upon reaching full extension of the lower leg, the effect is terminated (RF Patent No. 2421189).

Surgical treatment is used for all types of fractures of the intercondylar elevation with displacement, regardless of the size of the fragment and the degree of displacement.

A known method of treating a fracture of the intercondylar elevation of the tibia, including repositioning the fracture and fixing it with a knitting needle under the control of arthroscopy, using a 2-mm retaining needle using a fragment of the intercondylar elevation repaired by an arthroscopic probe in the direction from top to bottom, front to back, and outside to inside. of the anterior external arthroscopic portal and lead out in the area of the posterior interior surface of the medial condyle of the tibia, the upper end of the spoke is bent under glom 90 ° in a hook and tighten before immersion in osteochondral cartilage fragments intercondylar eminence (Patent №2375978).

A known method of metal osteosynthesis of fractures of the intercondylar elevation of the tibia in children, according to which arthroscopy is performed under standard anesthesia from standard access. From the lower medial access, a manipulator is inserted into the joint cavity. The manipulator under the control of an arthroscope performs the elimination of interposition and reposition of the fracture. After reposition, the internal medial arthroscopic access is expanded 3-4 cm down to the tibia. From the same access into the joint cavity under the control of an arthroscope, the osseous part of the L-shaped fixer is inserted, which fixes the fracture. The fastener part of the fixator after traction downward is attached to the proximal metaphysis of the tibia with two Kirschner spokes or two screws through the holes in the fixator. Rehabilitation until complete restoration of range of motion in the knee joint takes 3-4 weeks (Nikishov S.O. Intraartroscopic metalosteosynthesis of intercondylar elevation of the tibia in children: Abstract of dissertation for the academic degree, Ph.D.: M., 2004, p. 17-18).

A known method of surgical treatment of chronic rupture of the patellar ligament, including the use of an autograft on the leg to restore the ligament of the patella, while the tendon of the tender muscle, cut off from the muscle abdomen, is sequentially passed through a torn ligament of the patella to the opposite side, then through a previously formed transverse tunnel in the lower pole of the patella , again through the ligament of the patella to the tuberosity of the tibia, after which both portions of the tendon are sutured together, skostno fixed to the tibial tuberosity and the harbor cicatricial regenerate (patent №2471446).

A known method of osteosynthesis of periarticular fractures using a device in the form of a rod with curly periosteal and elongated fastening parts made of a material having the effect of double shape memory: first, the device is cooled and reduced, and when installed in the body, it takes its original shape. The rod is mounted on the bone in a cooled state, and the fastening part is installed in the drilled hole in the bone (Stuzhina V.G., Zar V.V. Diagnosis and treatment of injuries of the knee joints in children and adolescents. Sports Medicine Bulletin, 1993, No. 2-3 (4), p. 78).

There is a known method of osteosynthesis of intercondylar elevation according to McLennan, which consists in reposition under arthroscopic control of intercondylar elevation and fixation of the fracture with 2-3 Krishner spokes, carried out into the zone of the repaired osteochondral fragment retrograde through the condyles of the tibia, in the direction from the bottom up, and front to back, crosswise relative to each other (McLennan JG The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia // J. Bone Joint Surg. [Br]. - 1982. - Vol.64. - P.477-480).

The disadvantages of the method include the inevitable injury to the proximal tibial growth zone with a bundle of fixing knitting needles, as well as the long immobilization of the knee joint from 4 to 6 weeks, since there is a high probability of secondary displacement of the torn bone-cartilaginous fragment, due to the close proximity of the spokes and the tension vector of the anterior cruciate ligament .

This method is chosen by us as a prototype.

The present invention is the development of a less traumatic method for the surgical treatment of a fracture of the intercondylar elevation of the tibia in children.

The technical result of the proposed method is to ensure stable fixation of the torn bone-cartilaginous fragment in order to restore the integrity of the upper third of the tibia.

The essence of the method lies in the fact that in the method of surgical treatment of a fracture of the intercondylar elevation of the tibia, a minimally invasive intra-arthroscopic fixation of the fragment using a self-absorbable biodegradable implant is used.

The method is as follows.

Diagnostic arthroscopy is performed from the lower lateral port using a standard technique. After confirming the diagnosis, a shaver is inserted from the lower medial port into the joint cavity and the fracture bed of the intercondylar elevation of the tibia is treated. If available, the soft tissue can be eliminated. Under the control of an arthroscope and an electron-optical transducer, an anatomical reposition of the fracture is performed with temporary percutaneous fixation by the Kirschner spoke through the proximal tibia metaphysis. A damaged limb is bent in the knee joint at an angle of 90-100 degrees. On the medial edge of the upper pole of the patella, a skin incision of up to 0.5 cm is performed in the “two o’clock” position. Access the joint capsule in layers, bluntly and sharply and make a capsule incision up to 0.3 cm parallel to the edge of the patella. Under the control of an arthroscope, a guide needle with a diameter of 1.5 mm along the edge of fossa intercondylaris is manually inserted into the joint cavity through the formed medial port, without contacting the articular surface, in the plane parallel to the axis of the tibia towards the intercondylar eminence. Upon reaching the fracture site along the guide needle, a guide is inserted into the joint cavity through the medial port for osteosynthesis with a biodegradable implant, after which the needle is removed. Using the guide, the missing interfragmental fracture compression is achieved. The diameter of the implant is selected depending on the size of the bone-cartilage fragment. On the guide, a bone canal is drilled in the proximal tibia metaphysis corresponding to the diameter of the implant. To exclude damage to the intraarticular structures, the bone channel is drilled under the obligatory control of an arthroscope and itraoperative x-ray examination (EOP). Through the guide, along the formed channel, osteosynthesis of a fracture of the intercondylar elevation of the tibia is carried out with a biodegradable implant. Then, the retaining needle drawn through the proximal metaphysis of the tibia is removed.

If necessary, in order to achieve the greatest stability of the fragments at an angle to the first, but in the same plane, by a similar technique, install the second implant along the lateral edge of the upper pole of the patella, in the “at ten o’clock” position. The joint is repeatedly washed and sanitized, sutured to the skin, then aseptic dressing and plaster immobilization. In the early stages of the healing process, biodegradable implants support fixation. Over time, the implant gradually resolves, transferring loads on the healing tissue. In the human body, the implant disintegrates under the influence of hydrolysis, the remains of the implant are removed from the body naturally.

Biodegradable implants for osteosynthesis are polylactides, i.e. copolymers of L- and D-lactides (PLDLA) and a combination of L-lactide and glycolide, the so-called lactic acid (PLGA) manufactured in Finland (http://www.medtradcom.ru). The latches are represented by screws, simple and cannulated, and pins. From a chemical point of view, PLGA does not contain components that could adversely affect the biocompatibility of the product. PLGA monomers are lactic and glycolic acids, which are the normal chemical composition of mammalian cells. PLGA copolymers overcome the previously encountered problems that were associated with too rapid decomposition of PGA materials and the slow decomposition of PLLA materials, thereby neutralizing the biodegradable properties of both polymers. The PLGA copolymer used in the manufacture of biodegradable implants has a long history of safe clinical use and its biocompatibility has been proven in both animal and clinical trials.

Due to the fact that biodegradable implants dissolve over time, they gradually transfer the load to the fused bone, thereby actively contributing to the patient’s healing process, significantly reducing the risk of complications.

Clinical example of the method

Patient V., 15 years old, injured in July 2011 as a result of a fall from a bicycle. She was treated at a trauma center at the place of residence, 2 months after the injury, complaints of periodic swelling in the knee joint, pain, instability. At the place of residence, she received treatment for arthritis of the knee joint of unknown etiology with no result. After another exacerbation, they turned to the Research Institute of NDHiT. Diagnosis: Block of the right knee joint. A chronic fracture of the intercondylar elevation of the tibia on the right with a shift (Fig. 1, 2). Surgery is indicated.

A one-stage, reconstructive arthroscopic intervention was performed using minimally invasive osteosynthesis with biodegradable pins, aimed at restoring the normal anatomy and function of the affected large joint of the limb. Arthroscopy is made from the lower lateral access. During surgery, about 40 ml of dark blood with a large number of clots and an admixture of synovial fluid was obtained from the cavity of the right knee joint. The joint is washed and filled with saline. Visually, the synovial membrane in all departments is hyperemic, with pronounced hypertrophic villi. A fracture of the intercondylar elevation with an anterior and external displacement is determined, the fracture site is made in clots, there is an interposition of the fatty body, the latter is hypertrophied, with a pronounced vascular pattern and a large number of adhesions. No other pathology was found. The clots were removed if possible, the fracture site was treated with a shaver, tissue interposition was eliminated. A shaver was introduced from the lower medial access to the joint cavity, the fracture site was processed, scar tissue changed, adhesions were removed if possible. The Kirschner needle was inserted into the joint cavity. Under the control of an arthroscope, the fracture was repositioned, a fragment of the intercondylar eminence was temporarily fixed with a spoke. After two cuts up to 0.4 cm, osteosynthesis with two biodegradable pins transarticularly (1.5 × 50 mm and 1.5 × 40 mm) was made along the guide. The needle is removed, osteosynthesis is stable. The joint is repeatedly washed. Stitches to the skin. Aseptic dressing. Plaster cast. X-ray control - the condition of the fragments is satisfactory (Fig. 3). There are no neurocirculatory disorders.

After surgery, the diagnosis is confirmed: hemarthrosis of the right knee joint. A chronic fracture of the intercondylar elevation of the right tibia with displacement. Verticalization on crutches without relying on the right lower limb was carried out the day after surgery. X-ray control on the 10th day - standing fragments satisfactory, stable. Discharged from the hospital home in satisfactory condition, recommended crutches, without relying on a damaged limb. On the 37th day, the gypsum splint was removed during repeated hospitalization in the Department of Traumatology and Disaster Medicine of the Research Institute of NDH and T. Immediately after removing the retaining bandage during examination and control radiographs, the full range of movements of the right knee joint with chronic fractures of the intercondylar elevation of the tibia was recorded, the fragment was fixed, condition stable (Fig. 4, 5, 6). For the purpose of rehabilitation treatment, rehabilitation measures were carried out, namely, classes with an instructor of physiotherapy exercises, a course of magnetotherapy, was discharged from the hospital on the 10th day.

At the follow-up examination 1 year after surgery: no complaints, the girl is active, goes in for sports. The gait is correct. On examination, the joints are equal, warm, without hyperemia and local manifestations of inflammation, the full range of movements in the knee joints, symptoms of patellar balloting are negative on both sides, stress tests are negative (Fig. 7.8). An ultrasound examination confirmed the physical data: condition after arthroscopy, positive dynamics.

Using the proposed method allows to achieve low-traumatic intra-arthroscopic stable fixation of intraarticular fragments of the knee joint, with minimal damage to the growth zone, which helps to restore proper functioning, eliminates repeated surgical intervention for the removal of implants.

The proposed method allows to reduce rehabilitation treatment by more than 2 times, there is no need to stay in the clinic for a long time.

Claims (1)

A method of treating fractures of the intercondylar elevation of the tibia in children, including arthroscopic fixation of the fracture, characterized in that under the control of the arthroscope anatomical reposition of the fracture is performed with temporary percutaneous fixation of the Kirschner needle through the proximal metaphysis of the tibia, the injured limb is bent at an angle of 90-100 degrees at a angle of 90-100 degrees , along the medial edge of the upper pole of the patella, a skin incision of 0.4-0.5 cm is performed in the “at two o’clock” position, layerwise, bluntly and sharply produce n to the joint capsule and make a capsule incision 0.2-0.3 cm parallel to the edge of the patella, through the formed medial port, a guide needle with a diameter of 1.5 mm along the edge of fossa intercondylaris is inserted into the joint cavity, without contacting the articular surface, in the plane, parallel to the axis of the tibia, in the direction of the intercondylar elevation, a guide is introduced into the joint cavity through the medial port along the guide needle, after which the needle is removed, the bone canal is drilled in the guide in the proximal tibial metaphysis of the bone corresponding to the diameter of the implant, through the guide, along the formed channel, the osteosynthesis of the fracture of the intercondylar elevation of the tibia is carried out with a biodegradable implant, then the fixing spoke, made through the proximal metaphysis of the tibia, is removed and gypsum immobilization is performed.

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