RU2625651C1 - Method of closed reposition of bone distractions with intraarticular fractures of condyles of tibia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: injured limb is placed on the pedestal when the knee joint is bent at an angle of 165° and the position of the tibia is parallel to the surface of the operating table. Two fixing elements are introduced into each bone fragment, between the outer ends of which a different fixing element is transversely arranged and fixed by universal clamps of the rod fixation device. The X-ray source is oriented centrally to the knee joint slit from front to back at an angle of 7° to 10° with respect to the perpendicular of the long axis of the tibia in such a way that the conditional plane of the articular surface of intact segments of the tibial condyles coincides with the direction of the x-ray radiation. Manipulating the assembled structures under X-ray control, moving the bone fragments to the desired position until the x-ray image of a single line of the joint surface of the damaged and undamaged parts of the tibial condyles. Osteosynthesis is performed.

EFFECT: method allows to improve the quality of repositioning, to accelerate the restoration of joint function.

14 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used to reposition bone fragments with intraarticular fractures of the tibia.

In recent years, the frequency of severe intraarticular damage to the condyles of the proximal tibia metaepiphysis has been steadily increasing and reaches 60% of injuries of all joints and 2-5% of all skeleton injuries (Kuzina I.R.The role of magnetic resonance imaging in revealing “hidden” intraarticular fractures of the knee joint - New technologies in medicine: thesis, scientific and practical conference - Kurgan, 2000. - P. 151-153). Often such injuries are of a high-energy nature with a significant displacement of bone fragments, and their reposition is quite difficult due to the technical complexity of intraoperative imaging (French B., Tornetta P. / High-energy tibial shaft fractures // Orthop. Clin. North Am. - 2002. - Vol. 33. - P. 211). Arthroscopic control of the reposition of bone fragments in the considered fractures leading to splitting of the articular surface is not recommended because of the high risk of developing the tibia compartment due to the penetration of fluid from the cavity of the knee joint into the fascial cases of the tibia (Chen XZ, Liu CG, Chen Y., Wang LQ, Zhu QZ, Lin P. Arthroscopy-assisted surgery for tibial plateau fractures // Arthroscopy. - 2015.- N 31 (1). - P. 143-153).

The generally accepted method of intraoperative x-ray imaging also does not give a complete picture of the accuracy of reposition of bone fragments in the cases under consideration, since standard projections, usually used during surgery, do not allow a high-quality visualization of the articular surface of the tibial condyles. In addition, for high-quality reposition, it is necessary to ensure the ability to move displaced fragments of the tibial condyles in three planes without critical devitalization (destruction), which is technically very difficult if standard methods and means of reposition are used (I. Voronkevich, Surgical treatment of fractures of the tibial condyles (experimental-clinical research). Thesis for the degree of candidate of medical sciences, St. Petersburg, 2010).

A known method for the radiological diagnosis of bone injuries in the knee joint, namely, in a standing position with his back to the source of x-ray radiation, the patient presses his hips to the x-ray table, and the x-ray source is centered in the popliteal fossa with the beam deviating from the horizontal level 10 ° upward ( Vignon E., Pireno M., Le Graverand M.R., Mazzuca SA, Brandt KD, Mathieu P. et al. Measurement of radiographic joint space width in the tibiofemoral compartment of the osteoarthritic knee: comparison of standing anterioposterior and Lyon schuss views . - Arthritis Rheum. - 2003. - N. 48. - P. 378-384 .; Conrozier T., Mathieu P. , Piperno M., Prowedini D., Taccoen A., Colson F. et al. Lyon schuss radiographic view of the knee: utility of fluoroscopy for the quality of tibial plateau aligement. - J Rheumatol. - 2004.- N. 31. - P. 584-590.) However, the disadvantage of this technique is the impossibility of its intraoperative use in the position of the patient lying on his back.

There is also a method for radiological diagnosis of injuries of the knee joint, which consists in the fact that when the lower limb is straightened in the knee joint, the x-ray source is oriented perpendicular to the long axis of the limb with its center on the knee joint space (Sokolov V.M. - Medgiz. - 1955 - 304 p.). However, the disadvantage of this method is the mismatch of the direction of x-ray radiation to the plane of the articular surface of the tibia, as a result of which it is not possible to accurately assess the quality of reposition of bone fragments and the restoration of the normal configuration of the articular surface of the tibial condyles. In particular, it remains unclear whether, after reposition, the articular surfaces of the damaged and intact portions of the tibial condyles coincide.

In addition, there is a known method for surgical treatment of intraarticular and periarticular fractures of the knee joint (Gorodnichenko A.I., Teymurkhanly Fakhri Akif oglu, Uskov O.N. Method for surgical treatment of intraarticular and periarticular fractures of the knee joint. RU 2192191, Publish. 10.11.2002, ), consisting in the fact that three rods are inserted into the diaphysis of the femur along the outer surface or into the diaphysis of the tibia at the angles in the frontal and sagittal planes, a closed reposition of the intraarticular a fracture on an orthopedic table by distraction, for which, under the control of an x-ray image, spokes with thrust or tibial condyles are framed in the opposite direction, parallel to the articular surface, the rods and knitting needles are fixed with the help of the outer support of the rods, and the lateral compression of the bones fragments having an articular surface by tensioning the spokes in the spacers, and then reposition the fracture in the installed appar For this, for this purpose, a guide needle is additionally drawn through the condyles of the thigh or tibia, along which a rod with a thrust shoulder is screwed, then the guide needle is removed, and the rod is fixed in the outer support of the spoke device.

However, this method has significant drawbacks at the stage of closed reposition of bone fragments: the authors propose to perform it by distraction in an external fixation apparatus, followed by compression with counter spokes with thrust pads, which does not allow the movement of bone fragments in three planes. In addition, the final fixation of the fracture is proposed to be carried out only in the external fixation apparatus, which does not allow for the full implementation of rehabilitation treatment and causes inconvenience to patients. In addition, the authors do not specify the technique for the implementation of X-ray quality control of bone fragments reposition, which is important for achieving good results of surgical treatment.

The objective of the invention is to develop an effective method for closed reposition of bone fragments of the tibial condyles, displaced as a result of an intraarticular fracture, carried out under reliable radiological control and devoid of the above disadvantages.

The technical result of the invention consists in a high-quality closed reposition of fragments during intraarticular fractures of the tibial condyles with the reconstruction of the articular surface of these condyles under precise intraoperative x-ray control. In addition, the advantages of the proposed method are the reduction of the operation time and the speedy restoration of the function and range of motion in the knee joint, as well as the prevention of undesirable consequences associated with the development of post-traumatic gonarthrosis in the long-term postoperative period.

The result of the invention is achieved due to the fact that the injured limb is placed on a stand when the knee joint is bent at an angle of 165 ° and the lower leg is parallel to the surface of the operating table, two fixing elements are inserted into each bone fragment, between the outer ends of which there is another fixing element transversely and firmly fixed with universal clamps of the rod apparatus of external fixation, then the x-ray source is oriented with centering on the gap of the knee joint in front of azad at an angle of 7 ° to 10 ° with respect to the perpendicular to the long axis of the tibia so that the conditional plane of the articular surface of the intact portions of the tibial condyles coincides with the direction of the x-ray radiation, then, manipulating the assembled structures under x-ray control, move the bone fragments to the desired position until the x-ray image of a single line of the articular surface of the damaged and intact portions of the tibial condyles, after which nyayut osteosynthesis.

The figures depict:

Figure 1 - Computer 3D reconstruction of the fracture, top view. The displacement of a fragment of the lateral condyle of the tibia is clearly visible.

Figure 2 - The position of the lower limb of the patient on the operating table.

Figure 3 - The appearance of the mounted external device and the position of the image intensifier tube.

Figure 4 - Appearance of a magnetic goniometer attached to the arc of the image intensifier tube. The deflection of the protractor arrow by 8 ° is clearly visible, which corresponds to the inclination of the x-rays with respect to the perpendicular dropped to the longitudinal axis of the tibia.

Figure 5 - Closed reposition of bone fragments using the rigid system "fragment - fixing elements - tube."

Figure 6 - The position of bone fragments after a closed reposition. The articular surface of the intact portion of the lateral condyle of the tibia is visualized as a line. The coincidence of the line of the articular surface of the intact condyle of the condyle with the line of the articular surface of the bone fragment is clearly visible.

Figure 7 - Preliminary fixation of the fracture with a spoke.

Figure 8 - Radiograph of the patient after surgery (direct projection).

Figure 9 - Radiograph of the patient after surgery (lateral projection).

Figure 10 - View of the limb of the patient after surgery.

Figure 11 - Radiograph of a patient two months after surgery (direct projection).

Figure 12 - Radiograph of the patient two months after surgery (lateral projection).

Figure 13 - View of the lower limb of the patient two months after surgery (extension position).

Figure 14 - View of the lower limb of the patient two months after surgery (flexion position).

The method is as follows: first diagnosed with an intraarticular fracture of the condyles of the tibia according to clinical and radiological data. The damaged lower limb of the patient is placed on the operating table on a stand when bent in the knee joint at an angle of 165 ° and the position of the lower leg parallel to the surface of the operating table. Next, two fixing elements, for example, two spokes with a diameter of 2.5-3 mm or two Shants screws with a diameter of 3-4 mm, depending on the size of the bone fragment, are inserted transdermally into each displaced fragment of the tibial condyle of the tibia, placing them so that between their outer ends it was possible to arrange transversely another locking element. Then, the outer ends of the inserted fixing elements (knitting needles or Shants screws) are firmly fixed with the universal clamps of the external fixation rod apparatus and connected to each other by means of another fixing element, for example, a tube from the external fixation apparatus, forming a rigid system "bone fragment - intraosseous fixation elements inserted - external fixing element (tube) ”, as a result of which it becomes possible to move the displaced bone fragments in three movements by the assembled structure planes. Next, the X-ray source is oriented from front to back at an angle of 7 ° -10 ° (depending on the anatomical features of the proximal tibia of the patient) with respect to the perpendicular to the long axis of the tibia with its center on the joint space of the knee joint. In this case, the conditional plane of the articular surface of the tibial condyles should coincide with the direction of the x-ray radiation. In this case, the intact areas of the articular surface of the tibia are visualized as a line. Manipulating each displaced fragment using the external structure fixed in it, under direct x-ray control, the line of the intact articular surface of the tibia coincides with the line of the articular surface of the damaged condyle, which indicates a qualitative reposition. Then carry out preliminary fixation of the fracture with knitting needles and final osteosynthesis with a support plate and / or tightening screws.

Clinical example

Patient S., 36 years old, was admitted to the trauma unit with a diagnosis of closed fracture of the lateral condyle of the right tibia with displacement of fragments. The fracture was received as a result of a direct injury (a blow to the knee joint) during a game of football. To clarify the diagnosis, computed tomography was performed (Fig. 1). Fracture 41 B1 was verified according to the classification of the Osteosynthesis Association (AO). An operation was performed with closed reposition of bone fragments by the proposed method and fracture osteosynthesis with tightening screws. Surgery was performed as follows: after processing the surgical field, the damaged lower limb was placed on an X-ray transparent stand so that the bending angle in the knee joint was 165 ° with the horizontal position of the lower leg (Fig. 2).

After two punctures of the skin under the control of the image intensifier tube, two self-tapping Shants screws with a diameter of 4 mm at an angle of 35 ° to each other were introduced into the damaged condyle of the tibia. The ends of the Schantz rods located above the skin were connected to each other by means of a carbon fiber tube with a diameter of 11 mm from a set of external fixation devices and rigidly fixed with universal clamps, ensuring immobility in the "fragment - inserted intraosseously fixing elements - tube" system. The arc of the image intensifier tube (X-ray source) was oriented from front to back at an angle of 8 ° relative to the perpendicular to the long axis of the tibia with its center on the joint space of the knee joint. At the same time, it was achieved that the plane of the articular surface of the tibial condyles coincided with the direction of the x-ray radiation and the intact portions of the condyles were visualized in the form of a line (Fig. 3).

The angle of inclination of the x-ray source was determined using a magnetic protractor, which was attached to the arc of the image intensifier tube (Fig. 4). By manipulating the rigid system “fragment - inserted intraosseous fixation elements - tube”, the line of the intact area of the articular surface of the tibia coincided with the line of the articular surface of the damaged condyle on the X-ray image, which indicated a high-quality reduction of the bone fragment and the reconstruction of the articular surface (Fig. 5, 6) . Next, a preliminary fixation of the fracture was made with a knitting needle (Fig. 7).

Then, through two skin incisions with a length of 8 mm, each performed the final osteosynthesis of the fracture with two spongy screws with a diameter of 6.5 mm and a thread length of 32 mm. The wounds were sutured with single sutures. In figures 8 and 9 presents x-rays after surgery, and in figure 10 is a view of the limb of the patient after surgery. Active movements in the injured knee joint began from the first day after surgery. Three days later, the patient was discharged from the hospital for outpatient treatment.

The patient was examined two months after surgery. Radiological signs of fracture fusion were noted (Fig. 11, 12) with a complete restoration of the range of motion in the knee joint in comparison with a healthy limb (Fig. 13, 14). Permitted dosage load on the limb.

Claims (1)

A method of closed reposition of bone fragments during intraarticular fractures of the tibial condyles, including the introduction of fixing elements into the bone fragments under X-ray control and their closed reposition for subsequent osteosynthesis, characterized in that the damaged limb is placed on a support when the knee joint is bent at an angle of 165 ° and the position of the lower leg parallel to the surface of the operating table, two fixing elements are inserted into each bone fragment, between the outer ends of which are transversely located lay another fixing element and firmly fixed with universal clamps of the rod apparatus of external fixation, then the x-ray source is oriented with centering on the slit of the knee joint from front to back under the angle from 7 ° to 10 ° with respect to the perpendicular to the long axis of the tibia so that the conditional plane of the joint the surface of the intact portions of the tibial condyles coincided with the direction of the x-ray radiation, then, manipulating the assembled structures under the x-ray control, move bone fragments to the desired position until the x-ray image of a single line of the articular surface of the damaged and undamaged portions of the tibial condyles, and then perform osteosynthesis.

Images