RU2604769C1 - Method of long bone diaphyseal area fragments fusion in case of osteomyelitis damage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and orthopaedics and can be used for diaphyseal area long bones fragments fusion in case of osteomyelitis damage. Intramedullary canal at fragments ends is opened, on one of which cylindrical shaped receiving bed is formed, and second fragment end is treated congruently for its size in form of plug. Elastic perforated tube is introduced on receiving bed side via opening drilled in medullary canal. With matching of bone fragments tube is also immersed into intramedullary canal of opposite bone fragment. After formation of bone soldering rigid fixation is transferred into elastic by installation of springs on external fixation device threaded rods until complete fusion of bone fragments.

EFFECT: method enables reducing injuries, improve intramedullary canal drainage, improve blood supply.

1 cl, 8 dwg

Description

The invention relates to medicine, in particular to orthopedics, and can be used in the treatment of patients with osteomyelitis lesion of the diaphyseal region of a long tubular bone.

Treatment of patients with chronic osteomyelitis is not only a medical, but also a social problem. The frequency of unsatisfactory treatment results is quite high and ranges from 21% to 35%, and relapses of the disease are observed in 22-45%. More than 70% of them become disabled [6].

A known method of fusion of the ends of fragments after sequestrnecrectomy with osteomyelitis lesion of the diaphysis of the bone [1], which consists in the formation of a hole on one of the fragments, and the second spherically earn extra for it. This technique is ineffective with severe sclerosis of the ends of the fragments and occlusion of the spinal canal of these bone sections.

There is a method of treating patients with chronic osteomyelitis of the femur, combined with ankylosis of the knee joint in a vicious position, when, after sequestrating necrectomy of the affected area of the bone, the intact zone of ankylosis of the knee joint is preserved, the lower leg is fixed along the longitudinal axis of the proximal femur fragment, and the receiving bed is formed on the opposing side surface distal fragment. This technique is used only for ankylosis of the knee joint in a vicious position [2].

A known method of fusion of bones of the knee joint with osteomyelitis lesion. After removal of non-viable tissues, the fragments are mutually compressed and fixed to fusion using a compression-distraction apparatus, and during compression, the end of the femur is dosed dosed into the ends of both opposite shin bones, and their contact is blocked by a cut off fragment of the fibula and patella [3]. This method is used to fuse bones of the knee joint.

The prototype of the proposed method may be the technique of duplication of the ends of fragments of the type of "Russian castle". From a large incision, revision, sequestrnecrectomy and separation of the proximal and distal fragments are performed. Grooves are formed in the center of each of them and bone fragments are immersed in each other until they are locked into a lock-like joint [4], which eliminates mutual displacement along the width and contributes to an increase in thickness in the thinned area.

Drainage of the medullary canal along the longitudinal axis is impossible, and given the invasiveness of the intervention and the appearance of large shortening with such a comparison of fragments, it is advisable to apply the technique with excessive shortening.

The novelty of the invention consists in reducing the morbidity, the possibility of drainage of the medullary canal along the longitudinal axis and improving blood supply.

Significant differences: the method is carried out by opening the bone marrow canal at the ends of the fragments, on one of which a receiving bed of a cylindrical shape is formed, and the end of the second fragment is processed congruently to its size in the form of a plug through a hole drilled in the bone marrow channel from the receiving bed , introduce an elastic, perforated tube, when comparing bone fragments, the tube is immersed in the medullary canal and the opposite bone fragment, after the formation of bone adhesions, rigid fixation is converted into elastic by installing springs on the threaded rods of the apparatus until the bone fragments are fully fused.

SUMMARY OF THE INVENTION: FIG. 1a - Osteomyelitis bone before surgery.

After anesthesia and treatment of the surgical field, osteosynthesis of a limb segment is performed by an external fixation apparatus. When it is performed, the fixing knitting needles are carried out outside the zone of the osteomyelitis focus. In a tense state, the spokes are mounted on apparatus supports installed at the appropriate level, which are interconnected by threaded rods. Through an incision of soft tissues in the projection of the affected area of the bone, access to the osteomyelitis focus is made and sequestrnecrectomy is performed. An electric drill is used, axial tunneling of the sclerotic sections of the ends of the fragments to a depth, providing access to the unaffected sections of the medullary canal, is carried out with a milling cutter or a grooved bit. On one of the bone fragments, a receiving bed of a cylindrical shape is formed, and the end of the second fragment is processed congruently to its size in the form of a plug, through the hole drilled in the bone marrow canal, from the side of the receiving bed, an elastic, perforated tube is introduced (Fig. 1b), when matching bone its fragments are immersed in the plug. Fragments are compared with each other to close contact and in a predetermined position are fixed using an external fixation device. The operation is completed by wound closure, aseptic dressing and stabilization of the apparatus system.

In the postoperative period, starting from 5-7 days, ten days are metered approximation of the fragments to their end stop 0.25 mm four times a day. Then the nuts on the threaded rods fixed between the ring and the arc of the proximal and distal base of the external fixation apparatus are tightened. This creates a rigid fixation that promotes the formation of bone adhesions (Fig. 1B). A month later, after its formation, the external fixation apparatus is remounted, which consists in installing springs on threaded rods fixed between the ring and the arc of the proximal and distal base of the external fixation apparatus. Springs have a diameter corresponding to the diameter of the rods. The transfer of rigid fixation into elastic fixation promotes the transformation of bone adhesions into extensive bone callus at the junction of bone fragments in the form of a plug. This mode of fixation is maintained until a stable static-dynamic load is obtained (Fig. 1d). FIG. 1e - the result of surgical treatment (the osteomyelitis-affected area of the bone was removed, bone fusion was achieved).

The restoration of the required limb length is performed at the second stage of treatment or directly during the fusion. In the latter case, in addition to processing the ends of the fragments, an extension osteotomy of the bone is performed and a regenerate of the required size is formed. The adhesion strength is controlled by clinical testing and radiological.

The practical use of the method is illustrated by a clinical example.

Patient X., 32 years old, was admitted with a diagnosis of chronic hematogenous osteomyelitis of the right femoral fistulous form. To eliminate the pathological process zone and restore limb support ability, the patient underwent sequestrnecrectomy of the right femur, osteosynthesis with an external fixation device. During surgery, a fistulous passage is excised through a 7.0 cm long incision along the outer surface of the right thigh. A portion of the femur with an osteomyelitis focus was identified and sequestrnecrectomy was performed. Using an electric drill, a milling cutter, and using a grooved chisel, we performed axial tunneling of the sclerotic sections of the ends of the fragments to a depth providing access to the unaffected areas of the medullary canal. A cylindrical receiving bed was formed on the distal bone fragment, and the end of the second fragment was processed congruently to its size in the form of a plug. An elastic, perforated tube was inserted through a hole drilled into the bone marrow canal, from the side of the receiving bed, and when matching bone fragments, it was immersed in the plug. Fragments were juxtaposed to close contact and in a predetermined position were fixed using an external fixation apparatus. The operation was completed by wound closure, aseptic dressing and stabilization of the apparatus system. Elastic, perforated tube removed 10 days after surgery.

In the postoperative period, starting from 5-7 days, ten days were metered approach of the fragments to their end stop 0.25 mm four times a day. After that, the nuts on the threaded rods fixed between the ring and the arc of the proximal and distal base of the external fixation apparatus were tightened. This created a rigid fixation that promotes the formation of bone adhesions. A month later, after its formation, the external fixation apparatus was reassembled, which consisted of installing springs on threaded rods fixed between the ring and the arch of the proximal and distal base of the external fixation apparatus. The springs had a diameter corresponding to the diameter of the rods. This made it possible to translate rigid fixation into elastic fixation, which facilitates the transformation of bone adhesions into extensive bone callus at the junction of bone fragments in the form of a plug. This fixation mode was maintained until a steady static-dynamic load was obtained for 93 days. The fistula closed a month after the operation. Having received radiographs with signs of fusion, the threaded rods with springs were removed and a clinical test was performed. After ascertaining the fusion, the apparatus was dismantled. Additional immobilization was not required. He regularly attended classes of exercise therapy. At the time of dismantling the apparatus, the patient had a limb shortening of 5 cm. The patient refused to restore the limb length (Fig. 2-4).

Technical result: after sequestration necrectomy and osteosynthesis with an external fixation apparatus, the bone marrow canal is opened at the ends of the fragments, a receiving bed of a cylindrical shape is formed on one of them, and the end of the second fragment is processed congruently to its size in the form of a plug, this significant difference allows maintain alignment of the medullary canal. An elastic, perforated tube is inserted through a hole drilled into the medullary canal, from the side of the receiving bed. When matching bone fragments, the tube is immersed in the plug. The axial tunneling of sclerotic sections of the ends of the fragments to a depth that provides access to the unaffected areas of the medullary canal facilitates the evacuation of purulent contents and improves endosteal fusion. After the formation of bone adhesions, rigid fixation is transferred to elastic fixation until complete adhesion. This allows you to improve blood circulation in the area of periosteal fusion. A comparison of the fragments with each other to close contact in a given position with the creation of an elastic fixation condition and an early load in the affected segment also improves local blood circulation of the affected limb. Each of the significant differences is necessary and in combination to achieve the goal. The developed method can be used for all variants of controlled transosseous osteosynthesis, where it is required to achieve fusion of fragments of the diaphyseal region of a long tubular bone.

This method expands the range of possibilities: if necessary, allows you to perform bone osteotomy to eliminate shortening or deformation in one step.

At the follow-up examination, the achieved treatment result is saved after a year: there are no signs of the osteomyelitis process, the patient walks without support, in ordinary shoes, compensating for the shortening. Group III disabled person, employed. As a result, the purulent process was stopped and fusion of fragments in the correct position was achieved.

Sources of Information

1. Lapynin A.I. Il trattamento della pseudoartrosi del femore complicata da osteomielite cronica e suoi risul tati / V.E. Degtjarev, S.A. Paevskij // L′osteosintesi transossee secondo G.A. Ilizarov: Aspetti sperimentali, teorici e clinici / A cura di: A. Bianchi-Maiocci. Milano, 1985. P. 208-211.

2. Treatment of patients with chronic osteomyelitis of the femur, combined with ankylosis of the knee joint in a vicious position / N.M. Klyushin, T.A. Devyatova, A.I. Lapynin, V.E. Degtyarev // Genius of Orthopedics. 2003. No3. S. 146-148.

3. Pat. 2257173 Russian Federation IPC А61В 17/56. The method of fusion of the bones of the knee joint with osteomyelitis lesion / N.M. Klyushin, A.I. Lapynin, V.E. Degtyarev, E.A. Yeltsov. Announced on November 3, 2003; published on July 27, 2005. Bull. No. 21.

4. Shevtsov V.I. The method of transosseous osteosynthesis in the treatment of patients with chronic osteomyelitis / V.I. Shevtsov, A.I. Lapynin, N.M. Klyushin. Kurgan, 2001.221 s. (See pages 47-50).

5. New aspects of the Ilizarov method / A.I. Lapynin, A.N. Dyachkov, L.A. Popova, E.A. Mikhailova, A.V. Gubin. Kurgan, 2011.336 s. (See page 8).

Claims (1)

A method of fusion of fragments of the diaphyseal region of long tubular bones with osteomyelitis lesion, including the formation of a bed on one of the bone fragments to fix the end of the opposite fragment in it and osteosynthesis using an external fixation device, characterized in that the bone marrow canal is opened at the ends of the fragments, on one of which form the receiving bed of a cylindrical shape, and the end of the second fragment is processed congruently to its size in the form of a plug through a drilled into the medullary canal the e hole, from the side of the receiving bed, an elastic perforated tube is inserted, when matching bone fragments, the tube is also immersed in the bone marrow canal of the opposite bone fragment, after the formation of the bone adhesion, the rigid fixation is translated into elastic by installing springs on the threaded rods of the external fixation device until the bone is completely fused fragments.

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