RU2611742C1 - Method for surgery of ankle fractures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and can be applied for surgery of ankle fractures. Before osteosynthesis of fracture of external ankle collagen in form od gel is applied on its surface. Fixation of tibiofibular syndesmosis is realised with bioresorbable 4.0 or 4.5 mm screw after preliminary countersink of hole for screw head, with further application of 1/3-tubular plate above. After that, fracture of internal ankle is processed with collagen and fixed with two bioresorbable screws with incomplete thread.

EFFECT: method provides reliable fixation, possibility of earlier complete load on operated extremity.

Description

The invention relates to medicine, namely to traumatology, and can be used in the treatment of ankle fractures.

Fractures and fractures of the ankle joint (the bone base of the ankle joint is the lower part of the tibia, including the inner ankle, and the lower part of the fibula with the outer ankle and talus), and, in particular, fractures of the ankles account for up to 24% of all skeleton bone injuries and up to 60% of leg fractures (Semenisty A.Yu. Surgical treatment and rehabilitation of patients with ankle fractures, diss. candidate of medical sciences, M., 2005, p. 5).

Known functional operational method for the treatment of ankle fractures (US Pat. RF No. 2197191), which consists in an open reposition of fragments, their osteosynthesis, external fixation of the damaged segment of the lower leg with a plaster dressing "boot" or dressing of gypsum substitutes, characterized in that at first the fragments are fixed at fracture by immersion means of osteosynthesis, then support fixation sites are formed at three levels so that at least three not lying on one straight line are formed in the plane of possible displacement of bone fragments th site fixation levels of external fixation are rigidly interconnected to restore the support function of the damaged limb of the patient immediately learn to walk with a full load on the affected limb, to restore the function of damaged ankle superimposed means external fixation by the toes gradually shortened to a level of the ankle.

Plaster bandage fixation in the postoperative period allows to achieve fusion of the ligamentous apparatus of the ankle joint. However, this method obliges the patient to walk in the postoperative period up to 6 weeks in a plaster cast, which nullifies the benefits of surgical treatment.

A known method (US Pat. RF No. 2492832) for the treatment of fractures of the external ankle with a rupture of the tibiofibular syndesmosis, characterized in that they provide surgical access to the area of damage to the fibula, reposition the fragments and fixate them in the achieved position by installing through the performed surgical access arched curved metal structures, made of a material with a thermomechanical shape memory and having, on the side of one of the ends, a section with diverging extended elements, for which to the metal structure with a refrigerant, allowing it to straighten, then the metal structure is advanced in the transverse plane of the tibia by sliding along the posterior surface of the tibia and tibia with the transition to the inner surface of the tibia, grasping the articulated bones of the tibia from three sides and at the same time introducing the ends of the diverging extended metal elements one in each fragment of the fibula.

This method also forces the patient to use gypsum immobilization in the postoperative period due to insufficient structural strength.

To date, the most common and well-known method of surgical treatment of ankle fractures is the metal osteosynthesis of the inner ankle with metal screws, the outer ankle with a metal third-tubular plate. In this case, the generally accepted and most common fixation of the tibiofibular syndesmosis is carried out by a metal positional screw, which is installed through one of the holes of the plate after it is fixed on the fibula. The position screw is inserted in a strictly defined place, through the fibula in the oblique direction, posteriorly anteriorly at an angle of 25 ° -30 ° and parallel to the articular surface of the tibia through three cortical layers. It is located 2 cm proximal (above) the tibiofibular joint. After the performed metal osteosynthesis, a disciplining plaster cast is applied. The period of immobilization depends on the condition of the bone tissue, the activity and adequacy of the patient, the stability of metal fixation (Thomas P. Rudy, Richard E. Buckley, Christopher G. Moran, AO-principles for the treatment of fractures, 2013, pp. 886-893).

The disadvantages of the existing method:

1. After the joint of the fracture, it is necessary to perform an operation to remove metal implants, which is associated with significant trauma to the soft tissues both on the outer surface (an additional incision is made to remove the position screw, which is below the main surgical approach), and along the inner surface of the ankle joint.

2. The use of a metal position screw requires an intermediate operation to remove it before the full load starts, otherwise the latter will be destroyed. Removing a broken position screw is technically very difficult.

3. In case of ankle fractures with osteoporosis, the fragments are in hypovascular conditions that do not contribute to their fusion.

4. Installing the position screw in the second stage, through one of the holes of the plate, leads to the fact that periodically it is not possible to install the position screw in the right place due to limited points of insertion (hole of the plate).

5. In case of suppuration of the wound, removal of the metal plate along with the metal positioning screw is required.

The objective of the invention is to reduce the morbidity, reducing the time of rehabilitation postoperative treatment and achieving earlier terms of the full load on the operated limb.

The technical result is a reliable fixation of fractures of the ankles, allowing you to abandon external immobilization with plaster casts.

The problem is solved by the method of surgical treatment of ankle fractures, namely, before osteosynthesis of an external ankle fracture, a valve in the form of a gel is applied to its surface, the tibia syndesmosis is fixed with a 4.0 or 4.5 mm self-absorbable screw after preliminary re-counting of the screw head hole, overlay a third-tubular plate, then process the fracture of the inner ankle with a valve and fix with two self-absorbing screws with incomplete thread.

The method is as follows.

Before osteosynthesis of an external ankle fracture, a valve osteoinducer in the form of a gel is applied to its surface. Fixation of the tibiofibular syndesmosis is carried out with a 4.0 or 4.5 mm self-absorbable (biodegradable) screw from PLGA acids (85% lactic, 15% glycolic). Fixation, in contrast to the generally accepted method, is performed immediately after reposition of the external ankle fracture and fixation of the latter with a tightening screw. That is, the first stage fixes the tibiofibular syndesmosis with a 4.0 or 4.5 mm self-absorbing screw, and the second stage fixes the fracture completely with a metal third-tubular plate over the installed position screw. To do this, before installing the positional screw, countersink the hole with a vertical drill of the required diameter for this screw so that the screw head is not higher than the plane of the fibula. After reposition of the inner ankle, the fracture zone is treated in the same way with a gel-shaped valve, osteosynthesis of the ankle is performed using two biodegradable screws with incomplete thread of PLGA acids.

We present a clinical example of the implementation of the method of surgical treatment of ankle fractures.

Patient K., 35 years old. Diagnosis: Closed fracture of both ankles of the right lower leg with displacement of fragments. Complete rupture of the tibiofibular syndesmosis on the right. The patient underwent surgery under spinal anesthesia.

The patient is laid on an orthopedic table. 10 cm arcuate access was made, access to the external ankle of the right lower leg was made in layers. Fragments were refreshed, a valve in the form of a gel was applied to their surface. An open reposition and installation of a tightening 3.5 mm cortical screw was performed.

At the first stage, a canal is drilled in the fibula through 3 cortical layers at an angle of 25 ° under the control of an image intensifier tube, a hole is re-counted, a 4.5 mm position screw is inserted at a drilled angle of 25 °. The second stage after preliminary modeling of the third-tubular metal plate, lay it on the posterolateral surface of the fibula over the position screw, fix the plate with 3.5 mm screws. After reposition, the osteoinducer is treated with an internal ankle valve. The inner ankle is fixed with two self-absorbing biodegradable screws with incomplete thread of PLGA acids. EOP control. The standing of the fragments is satisfactory. Wound closure, aseptic dressing.

Sutures were removed on the 14th day after surgery. Healing by first intention. The patient is allowed a dosed load on the right lower limb up to 15 kg of body weight from 2 days after surgery. From the 6th week, a full load on the damaged lower limb is allowed. When walking, the patient switched from crutches to a cane.

After 2 months, control fractures showed consolidation of the fracture. The standing of the fragments has not changed. Ankle function has fully recovered. After 12 months, the operation to remove the metal. He started work after wound healing. The result of the treatment is marked as good.

The proposed method was tested on 10 patients, the results of surgical treatment in all cases are good. All patients returned to vigorous activity 14 days earlier than by the prototype method.

Thus, the method according to the invention provides reliable fixation of fractures of the ankles, eliminates the need for external immobilization with plaster casts. Fixation of the tibiofibular syndesmosis with a self-absorbable screw does not require its removal before the full load on the operated limb begins. Removing the ankle retainers requires surgical access 1.5 times less traumatic than during the well-known method because of the lack of the need to remove biodegradable screws from the inner ankle and position screw from the outer ankle. The use of the osteoinducer of the valve accelerates the process of fusion of the fracture and allows you to give a full load from 5 weeks after surgery. All this provides a reduction in the terms of rehabilitation treatment and early restoration of the function of the operated limb, the achievement of earlier deadlines for the full load on the operated limb.

Claims (1)

A method of surgical treatment of ankle fractures, which consists in the fact that before the osteosynthesis of an external ankle fracture a gel valve is applied to its surface, the tibia syndesmosis is fixed with a 4.0 or 4.5 mm self-absorbable screw after preliminary re-counting of the screw head hole, a third is applied on top - a tubular plate, then treated with a fracture of the inner ankle with a valve and fixed with two self-absorbing screws with incomplete thread.