RU2543854C1 - Arthrodesis technique for sacroiliac joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: three rods directed to the vertebrae S2, S3 are inserted at a depth of 5-8cm through crests; the first rod is attached within an anterior superior spine of the iliac bone; the other two rods extend at 1.5-2 cm and 3-4 cm respectively in the proximal direction. An apparatus is mounted on semi-ring supports to be connected to each other by threaded bars in front of the pelvis in parallel in the horizontal plane, and spaced at 3 cm from each other. Dynamic compression is generated in the frontal plane in the posterior pelvis.

EFFECT: method enables reducing the length of treatment and rehabilitation.

1 ex, 7 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of post-traumatic deforming arthrosis of the sacroiliac joints with persistent pain, as well as in the treatment of fresh and chronic injuries of the sacroiliac joints.

Known methods for arthrodesis of the sacroiliac joint, such as, for example, arthrodesis of the sacroiliac joint according to Smith-Peterson [1]: make an arcuate incision along the posterior contour of the iliac crest, cut the posterior ilium, cut the articular cartilage with a chisel. The resected iliac fragment is used as a graft. Immobilization in a plaster corset for 3 months.

The disadvantages of the method: trauma, the duration of immobilization, frequent unsatisfactory outcomes.

A less traumatic operation of arthrodesis of the hip joint is known [2], which consists in the following: transcutaneously, under the control of an electron-optical transducer (EOP), a guide needle is inserted into the vertebral body S1, through which the trocar is inserted to the joint. A curettage of the joint cavity is performed on the trocar, after which a biocomposite material is introduced into the joint. The operation ends with transpedicular fixation of the joint with cannulated screws.

Disadvantage: the inability to make up for compression in the joint in dynamics during treatment, the presence of an image intensifier tube in the operating room is required.

Closest in its technical solution to the claimed is a method of treating the sacroiliac joint [3]. The method includes the introduction of fixing elements into the ilium, osteosynthesis of lesions by an external fixation device, for which skin punctures are made in the region of the medial edge of the iliac wings. Through these punctures, retroperitoneally, rods are inserted into the ileal body near the sacroiliac joint, on both sides of the pelvis. The rods are interconnected using elements of the external fixation apparatus, and create compression between them in the frontal plane.

The described surgical treatment is characterized by a conditionally low trauma (“by means of a guide trocar, after drilling along the extracted needle, a rod-screw to a depth of 4-5 cm is inserted into the ilium, near the sacroiliac section”). In addition to the fact that the installation of a screw-rod in this way creates conditions for the evacuation of the retroperitoneal hematoma from the damaged side, disrupting the effect of tamponade, one must take into account the proximity of the large nerve plexuses when working with a trocar-conductor for drilling the ilium and introducing a screw rod. Moreover, taking into account the geometrical features of the inner surface of the iliac wing, an installed screw rod can cause pressure sores of retroperitoneal tissues in this area (iliac muscle, retroperitoneal fatty tissue, etc.). This is likely after the disappearance of the hydraulic effect of novocaine introduced into the retroperitoneal fiber according to Shkolnikov-Selivanov.

A pair-wise connection of fixators (rods-screws) inserted at the same level into the contralateral ilium by external fixation devices creates a significant concentration of stresses at the “rod-iliac bone” border during reposition and when creating compression between two rods in the frontal plane, which can lead to additional damage to the ilium. Without taking into account the localization of the axis of low-amplitude movement in the sacroiliac joints (S2, S3 vertebrae), where the moments of forces acting on the pelvic ring in the cranial and caudal directions are balanced, it is impossible to minimize the loads on the external fixation apparatus [4].

The purpose of the invention is to improve the results of treatment, while reducing its time, and reducing the number of complications, with a reduction in the rehabilitation of patients.

The essence of the invention is expressed by a combination of essential features sufficient to achieve a technical result, and consists in creating a stable local, if necessary adjustable during the treatment, compression in the rear parts of the pelvis, which ensures high efficiency of arthrodesis of the sacroiliac joint, and stabilization of the pelvic ring in whole.

The essence of the invention lies in the fact that the method of arthrodesis of the sacroiliac joint involves curettage of the articular surfaces of the sacroiliac joint from mini-access, insertion of the rods into both ilium of the pelvis, connecting them together using elements of the external fixation apparatus, and creating compression between the rods . Three rods are inserted into the body of the ilium, through the ridges, with orientation to the vertebrae S2, S3, to a depth of 5-8 cm. The first rod is installed in the region of the anterior superior iliac spine, the remaining two are proximal to 1.5-2 cm and 3-4 cm respectively. The apparatus is assembled on semi-ring supports, and the supports are interconnected by threaded rods located in front of the pelvis, in a horizontal plane, in parallel, at a distance of 3 cm from each other. Such a distance avoids the bulkiness of the external fixation apparatus and at the same time creates an effective linkage system. In the rear parts of the pelvis in the frontal plane create renewable compression dynamics.

The introduction of the rods through the ridges, with orientation to the vertebrae S2, S3, into the zone where the axis of low-amplitude movement of the sacroiliac joints is located and the moments of forces acting on the pelvic ring in the cranial and caudal directions are balanced [5], allows to provide minimal mechanical effect on the iliac bone during reposition of hemipelvis. The introduction of rods according to this scheme reduces the likelihood of additional damage to the ilium, allows you to achieve reposition of the pelvic bones with minimal effort, as well as minimize the load on the external fixation apparatus when the pelvis is balanced after reposition [4].

The use of three rods, with their introduction along the ileal crest to a depth of 5-8 cm, with a distance of 1.5-2 cm, ensures the strength of the system and the uniform distribution of bone tension transmitted from the rods.

Assembling the apparatus on semi-ring supports on each side of the pelvis, with the rods mounted on the ilium, taking into account the requirements of the general concept of the external fixation apparatus for the pelvis, creates a stable local, and if necessary regulated during the treatment, compression in the back of the pelvis. This ensures high efficiency of arthrodesis of the sacroiliac joint and stabilization of the pelvic ring as a whole.

The connection of the supports to each other with threaded rods located in front of the pelvis in the horizontal plane, in parallel, at a distance of 3 cm from each other, avoids the cumbersomeness of the external fixation device and creates an effective lever system. In the rear parts of the pelvis, in the frontal plane, a renewable compression is created.

The creation of dynamic compression in the posterior pelvis in the frontal plane allows, without complications, to achieve arthrodesis in the sacroiliac joint with relief of pain.

The method is illustrated in the illustrations, where:

figure 1-2 shows x-ray computed tomograms of the pelvis, with the installed external fixation apparatus, in a 3D image;

figure 3, 4 shows a diagram of an apparatus mounted on a basin:

figure 3 is a diagram in frontal projection, where 1 is the semicircular supports of the apparatus, 2 is the threaded rods, 3, 4 are the rods connecting the semicircular supports, 5, 6 are the specified directions of application of forces;

figure 4 is a rear view of the pelvis, where 7 is the compression direction.

figure 5 shows an x-ray of the pelvis of patient Sh., 2000, after osteosynthesis;

Fig.6 is a snapshot after arthroplasty, with the apparatus installed for arthrodesis;

Fig.7 is a snapshot after removing the apparatus.

The method is as follows.

In the patient’s position on the operating table on the abdomen, after processing the surgical field, in the projection of the middle third of the sacroiliac joint, an incision of up to 2 cm is made longitudinally to the joint. Bluntly, through the posterior portion of the sacroiliac joint, a channel is formed into the joint cavity. A thorough curettage of the articular surfaces of the joint is carried out with a raspator, a Volkman spoon. The treated cavity is washed, the wound is sutured. Drainage is set so that when creating compression in the rear parts of the pelvis, its infringement does not occur. Aseptic dressing. The patient is laid on his back, with a roller under the lower back.

Three rods 2 are inserted into the body of the ilium, with orientation to the vertebrae S2, S3, through the ridges 2 to a depth of 5-8 cm. The first rod is installed in the region of the anterior superior iliac spine, the other two are proximal to 1.5-2 cm and 3-4 cm respectively. The apparatus is assembled on semicircular supports 1, in the frontal plane create a dynamically compressible compression in the rear parts of the pelvis. In this case, the semi-ring supports 1 are connected to each other by threaded rods 3 and 4, located in front of the pelvis, in a horizontal plane, in parallel, at a distance of up to 3 cm from each other. Initially, compression is set in the frontal plane to the rear parts of the pelvis, for which the supports 1 are brought together the rod 3 in direction 5. Further, the compression is enhanced by the voltage of the rod 4, which is achieved by diluting the supports 1 in the direction 6. The forces creating compression in the rear parts of the pelvis in direction 7 in the apparatus should be palpable to the surgeon during the manipulation yatsiyah with the rods 3 and 4. In this case the rod 4 can be slightly deformed - bend. It becomes possible to regulate the compressive forces in the treatment process by bringing the supports closer together along the rod 3 in direction 5 and by expanding the supports with the rod 4 in direction 6.

Thus, the proposed method allows arthrodesis of the sacroiliac joint in compression mode in the rear parts of the pelvis, supported in dynamics. The method allows to activate the patient the day after surgery.

Clinical example

Patient Sh., 53 years old. In 1999, after an accident, she was treated conservatively (skeletal traction) in injuries, det. 15 gb Kazan about a closed pelvic fracture on the right with a displacement. After 9 months, she turned to the Scientific and Technical Center "WTO" with complaints of pain in the right hip joint, and stiffness of the right lower limb.

In 2000, in the SRC “WTO”, osteosynthesis was performed by an external fixation apparatus for a long-standing cross-fractured fracture on the right with an offset (Fig. 5). Dismantling the device after 9 weeks. With a diagnosis of: “Healed ancetabular fracture on the right with a displacement. Post-traumatic coxarthrosis on the right III-IV Art. Shortening of the right lower limb to 2 cm. Severe pain syndrome. " After 6 months, the hip joint was replaced with an installation of the Burschneider reinforcing ring on the acetabulum.

From the first days after activation, after osteosynthesis, the patient was disturbed by growing pains in the area of the right hip joint and in the area of the right sacroiliac joint. The instability of the pelvic component of the endoprosthesis against the background of the false joint in the area of the fused fracture of the acetabulum and the chronic damage to the right sacroiliac joint were clinically and radiologically determined. At a period of 9 months after arthroplasty, arthrodesis of the right sacroiliac joint in the external fixation apparatus was performed according to the developed method (Fig.6). In the patient’s position on the operating table on the abdomen, after processing the surgical field, in the projection of the middle third of the sacroiliac joint, an incision of up to 2 cm was made longitudinally to the joint. Bluntly, through the posterior portion of the sacroiliac joint, a channel was formed into the joint cavity. With a raspator, Volkman's spoon, a thorough curettage of the articular surfaces of the joint was performed. The treated cavity was washed, the wound was sutured. They installed the drainage so that when creating compression in the posterior parts of the pelvis, its infringement did not occur. Aseptic dressing. The patient was placed on his back, with a roller under his lower back.

Three rods were inserted into the body of the ilium, with orientation to the vertebrae S2, S3, through the ridges to a depth of 5-8 cm. The first rod was installed in the region of the anterior superior iliac spine, the other two were proximal to 1.5-2 cm and 3 -4 cm, respectively. The apparatus was assembled on semicircular supports; in the frontal plane, dynamic renewal compression was created in the rear parts of the pelvis. In this case, the semicircular supports were connected to each other by threaded rods located in front of the pelvis in a horizontal plane, in parallel, at a distance of up to 3 cm from each other.Initially, compression was set in the frontal plane to the rear parts of the pelvis, for which the supports were brought closer together along the proximal rod. Further, the compression was strengthened due to the voltage at the distal rod, which was achieved by breeding the half-ring supports. The surgeon felt the efforts creating compression in the rear parts of the pelvis during manipulations with the rods: the distally located rod was slightly bent. The opportunity was created to regulate the compressive forces in the treatment process by bringing the supports closer together in a proximal positioned bar and by extending the supports in the distal bar.

Dismantling the device after 8 weeks. There are no complaints. Radiographically, for a period of 4 months after the dismantling of the apparatus, there was an intergrowth fracture on the right, arthrodesis of the right sacroiliac joint (Fig. 7).

Information sources

1. Movshovich I.A. Operative orthopedics. - M.: Medicine. 1983 .-- 415 p.

2. RF patent No. 2428136, A61B 17/56, BI No. 25, 2011

3. RF patent No. 2381759, A61B 17/56, BI No. 5, 2010

4. Khabibyanov R.Ya. External fixation device for the treatment of damage to the pelvic ring. General concept // Practical medicine. - 2012. - No. 8 (64). - S. 62-63.

5. Lesgaft P.F. Selected works on anatomy. - M.: Medicine. 1968 .-- 370 s.

Claims (1)

The method of arthrodesis of the sacroiliac joint, including curettage of the articular surfaces of the sacroiliac joint from mini-access, introducing the rods into the body of the ilium on both sides of the pelvis, connecting them together using elements of the external fixation device and creating compression between the rods, characterized in that through the ridges, oriented to the vertebrae S2, S3, three rods are inserted to a depth of 5-8 cm, while the first rod is installed in the region of the anterior superior iliac spine, the other two are proximal 1.5-2 cm and 3-4 cm respectively, the apparatus is assembled on semi-ring supports, and the supports are interconnected by threaded rods located in front of the pelvis, in parallel, in a horizontal plane, at a distance of 3 cm from each other, in the front the planes create a dynamic compression in the posterior pelvis.

Images