RU2648863C2 - Method of two-stage arthrodesis of the knee joint at the defects of bones obtaining it - Google Patents

Abstract

FIELD: medicine; traumatology.

SUBSTANCE: invention relates to medicine, particularly to traumatology and orthopedics, and is intended for usage in performing arthrodesis of the knee joint to patients with defects in the bones forming it. After administration, the intramedullary rod is blocked proximally. Transosseous apparatus is applied over the rod. Wound is sutured without convergence of bone fragments. After wound healing, the ends of bone fragments are brought together by means of an external fixation device, the rod is blocked distally, and the external fixation device is dismantled.

EFFECT: method allows to provide optimal conditions for wound healing, prevention of soft tissue interposition and complications connected with a long period of fixation by a transcutaneous device.

1 cl, 11 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used to perform knee arthrodesis surgery.

A known method of arthrodesis of the knee using the so-called long intramedullary blocking rod (Eralp L., et al., 2007 [Eralp L. Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixation and an intramedullary nail. Surgical technique / L. Eralp, M. Kocaoqlu, H Rashid // J Bone Joint Surg [Am] 2007; Vol. 89-A. Suppl. 2 - P. 183-195.]).

According to this method, after processing the distal end of the femur and proximal end of the tibia, the bone marrow channels of the femur and tibia are opened. After that, from an incision 3-5 cm proximal to the apex of the greater trochanter, an intramedullary rod is inserted antegradely through the pear-shaped fossa. The ends of the fragments adapt. Under the control of the electron-optical transducer, the rod is blocked in the femur and tibia.

However, if there is an extensive defect in the bones that form the knee joint, when trying to approach the ends of the femur and tibia, there is a pronounced corrugation of the soft tissues. This makes it difficult or even impossible to close the wound. The use of soft tissue repair in such situations is also difficult due to pronounced cicatricial changes from repeated operations at the previous stages of treatment. Even if in such situations the wound can be sutured, the risk of necrosis of the edges of the wound and its divergence is very high.

Also known is a method of knee arthrodesis using external fixation devices (AVF). According to this method, after processing the distal end of the femur and proximal end of the tibia, the femur and lower leg bones are fixed with transosseous modules. After that, the ends of the bone fragments are brought together, transosseous modules are connected and created compression to optimize the conditions for the formation of ankylosis [Shevtsov V.I. et al., 1996; Conway J.D. et al., 2004; Oostenbroek, H.J. et al., 2001; Conway J.D. et al, 2004].

As with arthrodesis using a long intramedullary shaft, with AVF arthrodesis in the presence of a defect in the bones that form the knee joint, there is a high risk of corrugation of soft tissues with difficulty in suturing and a high risk of postoperative complications. At the same time, when using AVF, it is possible to suture the wound without converging bone fragments, which causes corrugation and divergence of the edges of the wound. After wound healing, using techniques of transosseous osteosynthesis, it is possible to bring together the ends of bone fragments and create compression. However, during wound healing (10-14 days), soft tissue interposition between bone fragments will occur, which even in the presence of compression can complicate the formation of ankylosis. In addition, during the convergence of the ends of the bone fragments due to muscle traction, a secondary displacement may occur, which will lead to a lack of good adaptation of the fragments. The disadvantages of transosseous osteosynthesis can also include a high risk of inflammation in the area of transosseous elements exit, inconvenience for the patient associated with the duration (up to 6-8 months) of fixation in the apparatus, as well as the need for such a long-term dynamic medical and nursing observation of them [Shaposhnikov Yu .G. et al., 1990; Paley et al., 2000; Woon C.Y-L. et al., 2010].

The technical result of a two-stage arthrodesis of the knee joint with a defect in the bones that form it is to provide optimal conditions for wound healing, prevention of soft tissue interposition and complications associated with a long period of fixation by transosseous apparatus.

The technical result is achieved by the fact that after the introduction of a long intramedullary rod, it is blocked only proximally, a transosseous device is placed “on top” of the rod, and the wound is sutured without convergence of bone fragments; after wound healing, bone fragments are brought together using AVF, the rod is distally blocked, and AVF is dismantled.

The drawings show:

FIG. 1 - Photograph of a defect in the bones that form the knee joint with an established long intramedullary shaft;

FIG. 2 - Photograph of soft tissues after convergence of bone fragments;

FIG. 3 - Photograph of a sutured wound in the presence of diastasis between bone fragments;

FIG. 4 - Radiographs with the presence of diastasis between fragments of the femur and tibia;

FIG. 5 - Photographs of soft tissues after convergence of bone fragments in the external fixation apparatus;

FIG. 6 - Radiographs after rapprochement of bone fragments;

FIG. 7 - Distal blocking of the rod under the control of the image intensifier tube;

FIG. 8 - Photographs of soft tissues after distal blocking of the rod and dismantling of the external fixation apparatus;

FIG. 9 - Tele-roentgenograms after distal blocking of the rod and removal of the external fixation apparatus;

FIG. 10 - Photos of the patient before surgery;

FIG. 11 - Photos of the patient after surgery.

The method is as follows.

After resection of the ends of the bone fragments and the introduction of a long intramedullary rod, the rod is blocked only proximal to the femur. After that, “on top” of the rod, an AVF is applied, in which the spokes and screw rods are eccentrically without contact with the intramedullary rod, or extracortical fixators are used [Utility Model Patent No. 87618]. The wound is sutured without rapprochement of bone fragments; even distraction by the apparatus “over” the rod is possible for better adaptation of the edges of the wound. After the wound has healed, on the 10-14th day after the operation, with the help of the AFF, the ends of the bone fragments begin to come closer together before their contact and compression. The approximation rate depends on the condition of the soft tissues and the size of the defect and can be from 1 to 5 or more mm per day. Upon reaching the contact of bone fragments and compression in the operating room, the rod is distally blocked in the tibia using the “free hand” method, and the external fixation device is removed.

The long shaft during the first stage of the operation is blocked only proximal in the femur to allow the tibia to move in the proximal direction. In addition, the core prevents the interposition of soft tissues.

AVF impose for the possibility of subsequent rapprochement of bone fragments "on top" of the intramedullary shaft.

Bone fragments at the end of the first stage do not bring together for the possibility of suturing the wound and creating optimal conditions for its healing.

The rapprochement of fragments using AVF begins after wound healing, in order to exclude the likelihood of developing vascular disorders as a result of corrugation of soft tissues.

AVFs are dismantled after creating interfragmentary compression and distal blocking of the shaft in order to increase the comfort of treatment for the patient and avoid complications associated with a long period of AVF fixation.

CLINICAL EXAMPLE

Patient Sh., 74 years old (Fig. 10). Diagnosis: Defect of the bones forming the right knee joint 10 cm. Non-articulating spacer of the right knee joint. Chronic osteomyelitis of the right thigh, lower leg, remission phase. In 2007, an operation of total endoprosthetics of the right knee joint was performed for right-sided gonarthrosis. In 2008, the replacement of the endoprosthesis was performed due to instability. In the postoperative period, fistulas formed. In 2009, an endoprosthesis was removed and an articulating spacer was installed. After 3 months - revision arthroplasty. In 2012, a repeated relapse of the infection. In 2014, an operation was performed: removal of an endoprosthesis, installation of a non-articulating spacer. 09/15/15, reconstructive plastic surgery was performed: removal of the non-articulating spacer, simulating resection of the distal end of the femur and proximal end of the tibia, arthrodesis of the right knee joint with transarticular fixation by an individual CITO rod in proximal blocking, superimposed AVF followed by matching fragments in time (Fig. . 1, Fig. 2, Fig. 3, Fig. 4). After reaching the junction of the bone fragments (Fig. 5, Fig. 6), October 12, 2015, the operation was performed: distal blocking of the rod, dismantling of the AVF (Fig. 7, Fig. 8). The residual shortening of the right lower limb 12 cm compensates for orthopedic shoes (Fig. 9, Fig. 11).

Claims (1)

The method of two-stage arthrodesis of the knee joint with defects in the bones that form it, including modeling the resection of the ends of the bone fragments, intramedullary osteosynthesis of the femur and tibia with a long shaft, application of an external fixation device, characterized in that after the introduction of the intramedullary shaft, the proximal block is blocked, the surface is applied , the wound is sutured without rapprochement of bone fragments; after wound healing, the ends of the bone fragments are brought together using an external fixation device, the rod is distally blocked, and the external fixation device is dismantled.

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