RU2626146C1 - Method for substitution of post-traumatic tibia defect - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: tibia osteotomy is performed at one level or fibular osteotomy is performed at the level of the tibia fracture. When the bone fragments are stretched for three to five centimeters, a dosed distraction is carried out along the inner rods of the apparatus until valgus deformation of the formed regenerate of 25-30 degrees appears. Subsequent distraction is performed along all rods. Pressure is used by an external clamping member of the compression-distraction apparatus designed to be superimposed on the tibia surface in the bone regenerates projection.

EFFECT: method allows to prevent blood supply violations, reduce the risk of purulent complications.

7 dwg

Description

The invention relates to medicine, in particular to traumatology and orthopedics, purulent surgery, and can be used in field surgery.

The problem of surgical treatment of patients with post-traumatic tibial defects is relevant, since the severity of injuries during anthropogenic, man-made and natural disasters is significantly increasing and, as a result, there is an increase in their number and adverse treatment outcomes.

State of the art

A known method of replacing a pathological section of a long tubular bone when controlled transosseous osteosynthesis of an affected limb segment is carried out (Copyright certificate for invention No. 3133533 of the USSR, MKI 3 A61B 17/00 Method of replacing a long tubular bone / G.A. Ilizarov; claimed 07.01.67; published 09/07/71. Bull. No. 27.). In this case, a resection of the affected area of the bone within healthy tissues is performed. Next, an osteotomy of one of the fragments is performed, the resulting middle fragment is fixed with traction needles with the possibility of its metered axial movement in the defect until it is compensated. The method is highly traumatic, accompanied by impaired blood circulation of bone fragments, which leads to delayed formation and rearrangement of bone regenerate.

There is a method for replacing a bone defect in patients with chronic osteomyelitis (Author's certificate for invention No. 1503775 USSR, MKI 3 А61В 17/00 Method for the treatment of chronic osteomyelitis with bone defect / S.A. Linnik, V.I. Savelyev and S.A. Filatov ( USSR); declared 01.16.1987; published 08.30.1989. Bull. No. 32.), when demineralized bone is placed in muscle tissue. Three months later, upon detecting the shadow of the newly formed bone on the roentgenogram, the second stage of surgical intervention is performed: the resulting bone autoregenerate together with the muscle is moved to a bone defect on the feeding leg. After suturing the wound, immobilization is carried out with a plaster cast. However, the formation of a bone regenerate from a demineralized bone site that is sewn into the muscle tissue is difficult to obtain; moreover, immobilization with a plaster cast does not allow this method to affect the bone regenerate in order to stimulate it, eliminate shortening and deformation of the limb. The method is highly traumatic (two stages) and the duration of implementation.

The known method (Shevtsov V.I. Rehabilitation of patients with chronic osteomyelitis and bone cysts / V.I. Shevtsov, A.I. Lapynin, A.V. Zlobin. - Kurgan, 2003. - 263 p. (See page 47) when osteotomy through the osteomyelitis cavity is carried out after sequestrnecrectomy, dosed distraction of the bone fragments until it is replaced by bone regenerate and restoration of the length of the segment with subsequent fixation using a compression-distraction apparatus. iem regenerate segment followed by reduction and compaction axis by compression of the dosage to stimulate bone formation and increase the volume of regenerate formed. However, to achieve regeneration and bone defect substitution posttraumatic used bone portions involved in osteomyelitic process that significantly reduces the efficiency of the process.

A prototype of the proposed method can be a technique for replacing a tibial defect with a fibula autograft on a vascular pedicle (Akin S., Durak K., One-stage treatment of chronic osteomyelitis of the proximal tibia using a pedicled vascularized double-barrel fibular flap together with a muscle flap // Br. J. Plast. Surg. 2002. Vol. 55, No. 6, P 520-523). However, this bone grafting is highly traumatic - it requires significant resection of the affected area of the tibia and fibula. The regenerative abilities of the resected and displaced fragment of the fibula are disrupted. The possibilities of correcting the length and deformation of the restored bone are limited. Graft fitting requires serious attention. A prerequisite is the excision of fistulas and a blind suture of the wound. Suppuration with transplant rejection is observed both in the early and later postoperative period. This is due to a number of reasons, the main of which are: thrombosis of the vascular pedicle of an autograft, insufficiently thorough sanitation of the focus, impaired blood supply in the affected area. In addition, regardless of the type of transplant material, when it is installed in the cavity, free blood-filled areas remain, which is a nutrient medium for a purulent-inflammatory process.

The novelty of the invention consists in replacing the tibial defect by stimulating osteogenesis by converging and combining bone regenerates of paired bones, using the concomitant defect, fracture of the same tibia, after its stable fixation by transosseous osteosynthesis and after the formation of bone adhesion, dosed distraction in order to obtain bone regenerate, use of an external clamping element.

Significant differences: The method is carried out in that the osteotomy of both tibia is performed at the same level and, when bone fragments are stretched by three to five centimeters, metered distraction is performed along the internal rods of the device until the valgus deformation of the regenerate formed appears at 25-30 degrees and subsequent distraction is performed on all the rods, with the aim of rapprochement and full contact of bone regenerates of the tibia, use pressure with an external clamping element of the design of the compression-distraction apparatus that applied to the surface of the lower leg in the projection of bone regenerates.

An example implementation of the method: FIG. 1a - damaged tibia before surgical treatment.

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 area of the bone defect. In a tense state, the spokes are mounted on apparatus supports installed at the appropriate level, which are interconnected by threaded rods. In the projection of the affected area of the tibia, they access the defect and remove non-viable tissues in the lesion. To compensate for a defect in the tibia, osteotomies of both tibia bones are performed at the same level or instead of an osteotomy, a fracture of the tibia is used.

From 7-8 days after the operation, metered distraction of bone fragments within 0.5-1.0 mm per day is carried out. In the process of distraction of both osteotomized or broken bones during the resulting trauma, distal or proximal to the bone defect bone fragments by three to five centimeters [Fig. 1b]. Then, in the previous mode, the metered distraction along the inner rods is continued until the valgus deformity of the regenerate by 25-30 degrees appears [Fig. 1c] and subsequent distraction over all the rods using an external clamping element [Fig. 1d] until the bone defect is recovered and the valgus deformity previously performed to bring the bone regenerates closer is removed [Fig. 1d]. The external clamping element consists of a plate connected by threaded rods to a rod or a second plate. [FIG. 5]. The latter are attached to the rings above and below the fibular regenerate. The plate is laid on the skin in the projection of the fibular regenerate. To bring the tibial regenerate closer to the tibial regenerate, traction of the threaded rods between the plates or the plate and the rod of the external clamping element is carried out as follows. This device is installed in the presence of bone regenerate five or more centimeters. A gauze or flannel gasket is placed under the plate of the external clamping element. By tensioning the threaded rods, the plate is emphasized on soft tissues and bone regeneration of the fibula by the plate until it is immersed by 2.0 mm. The exposure of such a voltage is one hour. Then the plate is removed from the surface of the lower leg, the skin is treated with an antiseptic. It is installed in its original place after an hour and the tension of soft tissue and bone regeneration of the fibula is created again by the plate before immersion up to 2.0 mm. An hour later, depreciation and backlash of the plate appear due to the convergence of the bone regenerate of the fibula to the tibial regenerate. The plate is removed again for an hour, and then the external clamping element is exposed 8–9 times a day with a break for day and night sleep, which is dismantled already at the fixation stage in the stage of organotypic reconstruction of bone regenerate [Fig. 5].

The adhesion strength is controlled by clinical testing and radiological.

FIG. 1e - the result of surgical treatment (the defect of the upper third of the tibia is compensated due to the bone regenerates formed and combined among themselves in the lower third of the tibia).

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

Patient A., 29 years old, was admitted 14 days after a car accident, at the time of which he received a defect of 12 cm of shin bones, and distal to him by a 15 cm fracture of the tibia [Fig. 2].

Operation: removal of non-viable bone fragments and areas of soft tissue, purulent contents, osteosynthesis by external fixation apparatus. To compensate for the defect of the tibia, a fracture of the tibia was used instead of an osteotomy [Fig. 3]. To stimulate its bone regenerate at the fracture level, an osteotomy of the fibula was performed in order to bring the bone regenerates of the tibia closer and contact. For this, from the seventh day after the operation, metered distraction of bone fragments was carried out in the range of 0.5-1.0 mm per day. After receiving a bone regenerate five centimeters long, dosed distraction was continued in the previous mode only along the inner rods until hallux valgus appeared in the regenerate region by 30 degrees [Fig. four]. At this time, an external clamping element was installed to bring the tibial regenerate closer to the tibial regenerate [Fig. 5]. To this end, traction of the threaded rods between the plates of the external clamping element was carried out. Using the tension of the threaded rods, emphasis was placed on the soft tissues and bone regeneration of the fibula by the plate before its immersion by 2.0 mm. The exposure of this voltage was one hour. Then the plate was removed from the surface of the lower leg, the skin was treated with an antiseptic. It was installed in its original place an hour later and the tension of soft tissue and bone regeneration of the fibula was again created by the plate before immersion up to 2.0 mm. An hour later, depreciation and backlash appeared due to the convergence of the bone regenerate of the fibula to the tibial regenerate. The plate was again dismantled for an hour, followed by exposure to an external clamping element in a predetermined mode 8-9 times a day with a break for day and night sleep.

Subsequently, distraction was carried out along all the rods using an external clamping element until the bone regenerates converged and their organotypic reconstruction [Fig. four].

Having received x-ray confirmation of the contact of the regenerates, they continued to compensate for the bone defect in the previous mode until it was eliminated, as well as the elimination of hallux valgus [Fig. 6]. The term of distraction is 155 days.

The final dismantling of the external clamping element was performed at the stage of fixation during the period of organotypic reconstruction of bone regenerate. The adhesion strength was monitored by clinical examination and radiological. Then the external fixation device is removed. The fixation period is 163 days. Additional immobilization was not required. He regularly attended classes of exercise therapy. At the time of dismantling the apparatus for limb shortening was not [Fig. 7].

Technical result: achieved by the fact that with sequestration necrectomy, necrectomy is performed with removal of bone fragments and sequesters, fixation using a compression-distraction apparatus. When compensating for a defect of the tibia, a fracture of the tibia is used instead of an osteotomy. To stimulate its bone regenerate at the level of the fracture, an osteotomy of the fibula is performed in order to bring together and full contact of bone regenerates of the tibia. From 7-8 days after the operation, metered distraction of bone fragments is carried out in the range of 0.5-1.0 mm per day. When a bone regenerate of five centimeters in length is obtained, metered distraction is carried out only along the inner rods until hallux valgus appears in the regenerate region by 30 degrees. Subsequently, distraction is carried out along all the rods using an external clamping element until the bone regenerates come closer together.

Upon contact of the regenerates, they continue to compensate for the bone defect in the previous mode until it is eliminated, as well as the elimination of hallux valgus. 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 compensation of a tibial defect complicated by purulent infection.

This method extends the range of capabilities and allows you to complete all tasks in one step.

Information sources

1. A.S. 3133533 USSR, MKI3 A61B 17/00 Method for replacing a long tubular bone / G.A. Ilizarov; Declared January 7, 67; published on September 7, 71. Bull. Number 27.

2. A.S. 1503775 USSR, MKI3 A61B 17/00 A method for the treatment of chronic osteomyelitis with bone defect / S.A. Linnik, V.I. Saveliev and S.A. Filatov (USSR); claimed 1/16/1987; published 08/30/1989. Bull. Number 32.

3. Shevtsov V.I. Rehabilitation of patients with chronic osteomyelitis and bone cysts / V.I. Shevtsov, A.I. Lapynin, A.V. Zlobin. - Kurgan, 2003 .-- 263 p. (see page 47)

4. Akin S., Durak K., One-stage treatment of chronic osteomyelitis of the proximal tibia using a pedicled vascularized double-barrel fibular flap together with a muscle flap // Br. J. Plast. Surg. 2002. Vol. 55, No. 6. P 520-523.

Claims (1)

A method for compensating for a post-traumatic defect of the tibia after removal of non-viable bone fragments, including fixation using a compression-distraction apparatus, characterized in that the tibia osteotomy is performed at the same level or the tibia osteotomy at the level of the tibia fracture and when the bone fragments are stretched by three to five centimeters carry out dosed distraction along the internal rods of the apparatus until the valgus deformation of the regenerate formed by 25-30 g dusov and subsequent distraction operate all the bars in order to approach and complete contact tibia bone regenerates, a pressure of an external pressure element design compression-distraction apparatus, imposed on the surface of the tibia bone in the projection regenerates.

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