RU2623298C1 - Method for open reposition and osteosynthesis of lower leg distal segment fractures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: during open reposition and osteosynthesis of lower leg distal bones fractures, combined osteosynthesis is applied using an external fixation device and plate-like metal detectors. Osteosynthesis is carried out in two stages. At the first stage, needles are directed through the middle of the heel bone from inside outwards at an angle of 15 degrees to the frontal plane of the ankle, then the needles not more than 2 mm in diameter are directed at the level of tibia tuberosity perpendicularly to the tibia sagittal axis, the external fixation device is assembled. At the second stage, open reposition and extramedullary osteosynthesis are performed under the conditions of distraction osteosynthesis. To do this, access is made along the back surface of the ankle and the lower third of the tibia, incision of skin and soft tissues is performed in parallel to the fibula, between the mid distance from the lattter and the Achilles tendon. The fibula length is restored, its temporary fixation is performed by needles. The final stabilisation of the fibula fracture is carried out with a bone metal fixator. The tibia fracture is exposed, repositioned and temporaryly fixed by needles. After an adequate level of fracture repositioning and congruence restoration in the ankle joint are obtained, the tibia fracture is stabilised by a extramedullary metal fixator, which is located on the posterior surface of the tibia. The needles are removed, the wound is sutured, using visual and EOC control.

EFFECT: method allows to achieve complete anatomical repositioning and stable fixation of bone fragments, to perform osteosynthesis of both shin bones from one access and to hide the metal fixators with a sufficient volume of soft tissues, so that prevention of necrosis and infectious and inflammatory complications, restoration of painless movements in the ankle joint are provided in the near postoperative period .

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Description

The invention relates to medicine, namely to traumatology and orthopedics, in particular, to methods used in the surgical treatment of intraarticular fractures of the distal leg bones by open reduction and bone fixation.

Known is a combined method of fixing intraarticular fractures of the ankle joint, in which an open reposition of fragments, their osteosynthesis are performed. A plaster bandage “boot” or a bandage of gypsum substitutes is applied to the damaged segment of the extremity of the “lower leg-foot”. In this case, first, the fragments are fixed at the fracture level by immersion osteosynthesis, then fixation support sites are formed at three levels so that in the plane of possible displacement of the bone fragments, at least three non-lying fixation sites are formed, the levels of external fixation are rigidly interconnected ( Patent No. 2197190RU. Published on January 27, 2003)

However, the known method is not intended for fixation of four-column intraarticular fractures of the distal leg bones.

A known method of treating intraarticular fractures of the distal leg is the use of a temporary combination of constant skeletal traction with submersible structures: a plate and screws. In this case, the fibula is repaired and fixed simultaneously with the tibia from the same surgical approach, using the same design. The screws are introduced from the inside outward at an angle of 30 ° to the frontal plane (Patent No. 2442546 RU. Publ. 20.02.2012).

However, despite the fact that the use of the known invention allows the effective fixation of fragments and fragments, it is not intended for fixation of four-column intraarticular fractures of the distal leg bones.

There is a method of transosseous osteosynthesis of lower leg bones, including holding the spokes through the metaphysical sections of the tibia above and below the fracture level with the installation of an apparatus based on rings, fixing the spokes in the ring with tension. In this case, a preliminary reposition of fragments of the tibia, distraction of fragments is carried out, and the final one is performed using a reposition unit equipped with rods inserted into the fragments in the lower leg corridor (Patent No. 2371137 RU. Publ. 27.10.2009).

However, the known method is not intended for fixation of four-column intraarticular fractures of the distal leg bones.

There is a method of treating complex pronation-eversion fractures of the distal articular part of the lower leg bones, in which reposition and fixation of the fracture of the fibula and fixation of the calcaneus are performed, with restoration of the anatomy of the ankle joint by shank bone rods, a rod inserted into the distal fragment of the fibula, inside the outside and back with a deviation of 18-25 ° from the frontal axis, is fixed in the bracket mounted on the annular support, the rod inserted into the calcaneus is fixed on the bracket, mouth mounted on a semicircular support of the apparatus, also with a deviation of 18-25 ° from the front axis. assemble the external fixation apparatus by connecting the proximal annular and distal semicircular supports, the method allows to reduce the risk of deforming arthrosis and contractures (Patent No. 2551303 RU. Publish. 05.20.2015).

However, the known method is not intended for fixation of four-column intraarticular fractures of the distal leg bones.

A known method of treating fractures of the distal metaepiphysis of the tibia, including conducting an open reduction and internal fixation of a fracture of the tibia and fibula from two separate accesses. The method consists in open reduction and bone osteosynthesis with a tibial fracture plate made from anteroposterior access and open reduction and bone osteosynthesis with a tibial fracture plate made from an external access (Canale ST Campbell's operative orthopedic / ST Canale, JH Beaty. -Philiaphierphiaphiaphiaphiaphia pheilphiaphiaphia pheilphiaphiaephiaphia pheilphiaphiae 2013, vol. 3. p. 2632-2646).

However, the disadvantages of this method are:

- the need for two separate accesses to each bone, which creates a number of difficulties in suturing wounds, and can have adverse consequences for the healing of postoperative wounds, the latter due to a weakly expressed soft tissue case in the ankle joint and lower third of the leg.

- in the known method, the reconstruction of the distal part of the leg bones is carried out by open manual reposition of fracture fragments, arising during reposition of the complexity, usually associated with the restoration of the axis and length of not only the fibula, but also of the tibia, with an unstable nature of damage to the latter (polyfocal four-column fractures, line which extends proximally to the diaphysis).

- All of the above leads to a lengthening of the operating session. A known method of treating intraarticular fractures of the distal bones

lower legs according to G.A. Ilizarov, in which osteosynthesis begins with the installation of a module based on two supports: the proximal base and repositional-fixation (AVF). An annular support is fixed to the indicated module at level VIII of the lower leg. Next, mount the support on the foot. They grab the support with their hands, attempt an enclosed manual reposition of the fragments, after which the distal support is connected with 3-4 rods to the base apparatus and a distraction force is applied. Perform x-ray control. Next, a knitting needle VI, 3-9 is carried out at the level of the repositional-fixation ring of the lower leg, which allows correction of the position of the proximal fragment and its stabilization (Solomin L.N. Fundamentals of transosseous osteosynthesis with the apparatus of G.A. Ilizarov: Monograph. - St. Petersburg, LLC MORSAR AB ”, 2005. - 544 p.).

The disadvantages of this method are:

- surgical treatment in a known manner involves static fixation of the ankle joint for a sufficiently long period, which excludes the possibility of early rehabilitation with subsequent development of movements in the ankle joint and can lead to the development of contractures;

- holding the spokes through the fragments of the fracture increases the risk of perifocal spoke infectious complications.

- the use of this method is limited for fractures accompanied by a defect in bone tissue.

A known method of treating fractures of the distal metaepiphysis of the tibia, including conducting open reduction and internal fixation of a fracture of the tibia and fibula from a single access with one plate. The method consists in laying a damaged limb on an upgraded Beller operating bus. Under conditions of skeletal traction over the calcaneus with a load of 5-7 kg, a closed reposition of the fibula is performed with restoration of its length by introducing screw rods above and below the fracture site, followed by fixation of the rods in the external support. Access to the tibia is carried out in the lower third, the latter goes along the line connecting the tuberosity of the tibia and the middle of the ankle joint distal to the articular fissure by 1.5-2.0 cm. After an open reposition, the tibia and fibula are fixed with a plate, the latter is laid on the medial surface of the tibia, screws are inserted through both bones at an angle of 94-100 ° to the plane of the medial surface of the diaphyseal part of the tibia (Kondratiev I.P. the first treatment of fractures of the distal part of the leg bones // Diss. Candidate of Medical Sciences, St. Petersburg - 2014).

However, the disadvantages of this method are:

- the use of constant skeletal traction as stage 1 does not allow for adequate ligamentotaxis, since traction goes only through the calcaneus

- the use of only one plate located on the medial surface does not always allow stably fixing fractures of the anterior and posterior tibial columns.

- joint fixation of both the tibia and fibula at several levels violates the biomechanics of movements in the ankle joint, due to the lack of vertical play of the fibula, can be an indirect prerequisite for the formation of contractures in the joint

A known method of treating fractures of the distal metaepiphysis of the tibia, by means of closed hardware intraoperative reposition of the posterior edge of the tibia. The method is based on the method of closed reduction of a fracture of the posterior edge of the tibia using a reponent element and AVF of two half rings located above the fracture site on the posterior surface of the lower leg (Chermakov K.S. Minimally invasive osteosynthesis of posterior marginal fractures of the distal epiphysis of the tibia // Diss. Kand Medical Science, Cheboksary 2010.145 s.).

However, the use of the known method is intended only for single-column fractures of the distal tibia without fragmentation and impression of bone tissue, limiting the possibility of open reduction and fixation of the plate of fractures of the tibia from the posterior approach, fixation of the fibula from a separate access.

There is a method of modular transosseous osteosynthesis of lower leg bones, in which four spokes in the frontal plane are passed through the metaphysical divisions of the tibia, above and below the fracture level. Insert rods-screws parietally and parallel to the outer cortical plate of the tibia. Mount the apparatus on the basis of four rings. Intermediate reposition-fixation supports are mounted from sectors based on 3/4 of a ring and 1/3 of a ring. Sectors based on 1/3 of the ring are oriented along the anteroposterior surface of the lower leg and are fixed to them by two screw rods, the angle of introduction of one of them being open towards the fracture level, and the angle of introduction of the other in the opposite direction. In the postoperative period, based on the clinical and radiological dynamics of healing of the bone wound, first the extreme supports and then the sectors based on the 3/4 ring of the intermediate reposition and fixation supports together with the repairing needles are dismantled (Patent No. 2310408 RU. Publish. November 20, 2007) .

A known method of osteosynthesis with a pivotal apparatus for fractures of the lower leg bones, in which preliminary reposition of fragments is carried out; rods are inserted into the proximal and distal metaphyses of the tibia at an angle of 40-45 ° to the frontal plane, one rod is inserted in the frontal plane, at a distance of 2-3 cm above and below the fracture, the rods are attached to the beam, which is located anterior to the inside of the tibia bones. After reposition of the fragments, the knitting needles are carried out: one in the frontal plane through the proximal metaphysis of the tibia, the second through the distal metaphysis of both tibia, the needles are fixed to two half rings (Patent No. 2218888 RU. Publish. 12.20.2003).

However, the known method is not intended for combined osteosynthesis of multi-fragmented intraarticular fractures of both lower leg bones from a single access and using immersed bone plates.

The objective of the present invention is the controlled reposition and osteosynthesis of multi-fragmented intraarticular fractures of both lower leg bones from a single access, the result being the optimal covering of fixators with soft tissues, which ensures the prevention of necrosis and infectious-inflammatory complications in the immediate postoperative period, and the restoration of painless movements in the ankle joint .

The problem is solved in that in the method of open reposition and osteosynthesis of fractures of the distal part of the lower leg bones, including osteosynthesis with an external fixation device, dosed reposition and fixation of bone fragments, osteosynthesis is carried out in two stages, while at the first stage, knitting needles are made through the middle of the calcaneus from the inside out at an angle of 15 degrees to the frontal plane of the ankle joint, then conduct needles no more than 2 mm at the level of the tibial tuberosity perpendicular to the sagittal axis of the tibia of the radial bone, the external fixation apparatus is composed, at the second stage, under the conditions of distraction osteosynthesis, open reposition and bone osteosynthesis are performed, for this, access is made along the posterior surface of the ankle joint area and the lower third of the lower leg, while the skin and soft tissues are cut parallel to the fibula, between the middle of the distance from the last and the Achilles tendon, access begins 5-7 cm proximal to the fracture and is led down to the apex of the lateral ankle, skirting the latter from back to front, restore the length of the fibula, reposition the residual displacements of the fracture of the fibula and carry out its temporary fixation with needles, final stabilization of the fracture of the fibula is performed by the bone metal fixator, then expose the fracture of the tibia, carry out its reposition and temporary fixation with the needles, achieve an adequate level of reposition of the fracture and in the ankle joint, a fracture of the tibia is stabilized by the osseous metal fixator, which placed on the back surface of the tibia, the needles are removed, the wound is sutured, use visual and image intensifier control.

In an embodiment of the method, with the polyfocal comminuted nature of the fracture of the front and inner tibial columns to ensure greater stability, it is advisable to additionally lay an additional metal plate equal to 1/3 of the tubular plate along the front and / or inner surface.

The present invention is illustrated by a detailed description, a clinical example of its implementation and copies of radiographs, on which:

FIG. 1 (a, b) presents copies from radiographs of the ankle joint in the direct (a) and lateral (b) projections with a comminuted intraarticular fracture of the distal part of both bones of the leg and violation of congruence of the ankle joint;

FIG. 2 presents intraoperative photographs, which show the performance of an open reposition and internal fixation of both bones of the lower leg from one access in the conditions of the module of the distraction circular external fixation apparatus;

FIG. 3 (a, b) presents copies from radiographs of the ankle joint in the direct (a) and lateral (b) projections of patient B., 26 years old, after surgery: congruence of the ankle joint was restored.

The method is as follows.

The external fixation distraction apparatus is formed by holding the knitting needle through the middle of the calcaneus from the inside outwards at an angle of 15 degrees to the frontal plane of the ankle joint. Spokes are carried out, not more than 2 mm in diameter at the level of the tibial tuberosity, perpendicular to the sagittal axis of the tibia. Select the arc supports of the circular external fixation apparatus, depending on the size of the lower damaged limb of the patient. The drumstick is placed in the frame of the AVF, which is composed of two supports, in particular half rings. The said half rings are placed proximal and distal to the lower leg. Then the supports are interconnected by two telescopic rods. In this case, 1 (one) rod is installed on the posterior-internal, and 2 (second) - on the anteroposterior surface of the lower leg. To exclude screening of the stages of reposition, image intensifier tubes are used. In the conditions of the external fixation apparatus, an open reposition and bone osteosynthesis are made. Access is provided along the posterior surface in the ankle joint and the lower third of the leg. The incision of the skin and soft tissues is carried out parallel to the fibula, between the middle of the distance from the last and the Achilles tendon. Access begins 5-7 cm proximal to the fracture and is led down to the apex of the lateral ankle, enveloping the latter from back to front.

At the first stage, under the conditions of an external fixation apparatus, controlling the distraction visually, as well as with the help of a tube, restore the length of the fibula. After that, the residual displacements of the fracture of the fibula and the temporary fixation of its fragments with needles are repositioned. Repeatedly conduct image intensifier testing. With a satisfactory position of the fragments of the fibula, the final stabilization of the fracture is carried out by the osseous metal fixator according to generally accepted rules, namely, an additional 1/3 of the metal plate or reconstructive metal plate. Then, in a sharp and blunt way, a tibial fracture is exposed, the latter is repositioned and then temporarily fixed with knitting needles. Carry out additional image intensifier tubes. With an adequate level of reposition of the fracture and restoration of congruency in the ankle joint, the fracture of the tibia is stabilized by the bone metal fixator according to generally accepted rules, namely: a modeled combined LCP plate laid on the back surface of the bone. The spokes are removed, the wound is sutured.

With the polyfocal comminuted nature of the fracture of the front and inner tibial columns, an additional 1/3 of the tubular plate is laid along the front and / or inner surface as a support and anti-slip from the minimum accesses.

Clinical example of the method

Patient B., 26 years old, received a sports injury while skiing, was taken by the ambulance team to the emergency room of the Central Clinical Hospital No. 24; Ekaterinburg. In the emergency room, the diagnosis was made: “Cellular polyfocal four-column intraarticular fracture of the distal part of both leg bones” (Fig. 1).

During hospitalization in the trauma unit No. 1, it was decided to carry out surgical treatment in the amount of open reduction and osseous fixation with plates. On the ninth day after admission and preoperative examination, the patient was taken to the operating room. After anesthesia, the patient was laid on the operating table in the supine position. Under sterile conditions, a module (lower leg-foot) of an external fixation apparatus of two supports and telescopic rods was mounted on the lower damaged limb. To both bones of the distal tibia, posterior external access was made (Fig. 2).

During the revision of the fracture, there was a significant shortening of the fibula. Under the control of the image intensifier, metered distraction was performed until the normal anatomical relationship of the fibula was restored. After optimal distraction and reposition of fractures of both bones, osteosynthesis with bone metal fixators was performed. The wound was sutured in layers tightly. The inner tibial column was additionally synthesized from a separate internal access in the ankle joint along the inner surface by a small straight plate as a support plate (Fig. 3).

The proposed method for open reduction and osteosynthesis of distal shin bone fractures from one access allows eliminating a four-column distal shin bone fracture, which is safe and economical.

In addition, the proposed method allows to achieve complete anatomical reposition and stable fixation of bone fragments, to perform osteosynthesis of both bones of the leg from a single access and to cover metal fixators with a sufficient volume of soft tissues.

The proposed method allows for a complete anatomical reposition of an intraarticular fracture, early painless functioning of the ankle joint with restoration of the full range of movements, provides for the prevention of infectious and inflammatory complications in the near postoperative period

The method is used in the Central city clinical hospital No. 24 of the city of Yekaterinburg.

Claims (2)

1. The method of open reposition and osteosynthesis of fractures of the distal bones of the leg, including osteosynthesis with an external fixation device, dosed reposition and fixation of bone fragments, characterized in that osteosynthesis is carried out in two stages, while the first stage is carried out by knitting needles through the middle of the calcaneus from the inside out under angle of 15 degrees to the frontal plane of the ankle joint, then conduct needles no more than 2 mm in diameter at the level of the tibial tuberosity perpendicular to the sagittal axis of the tibia bones, the external fixation apparatus is assembled, in the second stage, under conditions of distraction osteosynthesis, open reposition and bone osteosynthesis are performed, for this, access is made along the posterior surface of the ankle joint area and the lower third of the leg, and the skin and soft tissues are cut parallel to the fibula, between the middle distances from the last and the Achilles tendon, access begin 5-7 cm proximal to the fracture and lead down to the apex of the lateral ankle, bending the latter from back to front, restoring they build the length of the fibula, reposition the residual displacements of the fracture of the fibula and carry out its temporary fixation with needles, final stabilization of the fracture of the fibula is performed by the bone metal fixator, then expose the fracture of the tibia, carry out its reposition and temporary fixation with the needles, achieve an adequate level of reposition of the fracture in the ankle joint, a fracture of the tibia is stabilized by the osseous metal fixator, which is located they dig on the posterior surface of the tibia, the needles are removed, the wound is sutured, visual and image intensifier tubes are used. 2. The method according to p. 1, characterized in that additionally on the front and / or inner surface of the tibia from the anteromedial access, an additional metal plate equal to 1/3 of the tubular plate is laid.

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