RU2655108C1 - Device for external fixation of long tubular bones - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: device is made of wire for cerclage. Wire with a diameter of 1 mm has a length of 90 to 140 mm and is flattened at 2/3 - 3/4 of its length in the center and at the ends, and has a width of 1.5-2.0 mm and a thickness of 0.5-0.7 mm, with transverse dents on the concave side of the central portion.

EFFECT: reduced time of intraoperative manipulation and the entire operation of submerged osteosynthesis.

1 ex, 5 dwg

Description

The invention relates to medical equipment, namely to devices used in traumatology and orthopedics.

During the operation of immersion osteosynthesis of long tubular bones, wire cerclage is often used. For example, with an oblique, spiral and longitudinal fracture lines or when fixing a bone fragment to its bed, to enhance mutual adaptation between bone fragments around the tubular bone, wire cerclage is carried out, the ends of which are twisted with pliers, needle holders or clamps with hard jaws (Fig. 1, a ) At the same time, twist the ends of the wire cerclage to regulate the degree of mutual adaptation of bone fragments. For the same purpose, you can use various options for a metal tape, for example, Putti tape (Fig. 1, b), a combination of wire cerclage with staples (Fig. 1, c), the use of special plates without holes for fixing bone fragments using cerclages (Fig. 1, d).

A common drawback of all of these analogues is, on the one hand, the lack of stability of osteosynthesis with the need for prolonged external immobilization and the inevitability of the development of its accompanying complications (joint contracture, muscle atrophy and osteoporosis), and on the other, atrophic disorders occur in bone-crushed bone fragments. The latter along with impaired reparative regeneration, delayed fracture fusion, osteolysis under cerclage with loss of stability of fixation of bone fragments can lead to a false joint, aseptic necrosis, sequestration of the bone and osteomyelitis. Consequently, these devices for osteosynthesis of long tubular bones are combined with a wide range of significant drawbacks - from osteosynthesis inefficiency to a high risk of complications that translate one pathological condition into another, often more serious and painful for the patient. To date, it is considered immutable that unstable osteosynthesis is contraindicated in patients with high functional needs.

As a prototype of the proposed device, we selected wire cerclage for osteosynthesis (Fig. 1, a), described in many manuals, including the monograph by A.Yu. Nabokova "Modern Osteosynthesis" (2007). The essence of the prototype device and its application is that when oblique, spiral and longitudinal fracture lines or when fixing a bone fragment to its bed, to enhance mutual adaptation between bone fragments around the tubular bone, a wire for osteosynthesis, with a diameter from 0.5 to 2.0 mm, the ends of which are twisted with pliers or other tools with rigid jaws (Fig. 1, a). At the same time, twist the ends of the wire cerclage to regulate the degree of mutual adaptation of bone fragments and thereby ensure the stability of osteosynthesis.

Prototype criticism

The use of wire cerclage for submersible osteosynthesis, especially when using round wire, as a rule, is considered only as a necessary measure in addition to intramedullary or bone osteosynthesis, to enhance its stability and mutual adaptation of bone fragments. This is due to atrophic changes in bone fragments under the cerclage (the wire “strangles the bone”), which, along with the violation of reparative regeneration and delaying the healing time of the fracture, is associated with the risk of serious complications. So, under a wire stretched by twisting of its ends, osteolysis can occur with a secondary loss of stability of fixation of bone fragments, a false joint, aseptic necrosis, sequestration of bone sites and osteomyelitis can form. Therefore, to prevent these complications, many experts recommend removing the wire with a more or less pronounced fracture consolidation already 1.5-2 months after surgery. That is, there is a need to perform an additional operation to remove cerclage wire. The other part of the metal structure - the intramedullary shaft or plate with screws - is removed after 6-12 months. Other authors recommend that you do not consciously hold out the twist of the ends of the cerclage, leaving a gap between the wire and the bone, thereby minimizing the likelihood of ischemia of bone fragments. However, this is fraught with instability of osteosynthesis and the lack of adequate mutual adaptation of bone fragments, the risk of their secondary displacement and the associated serious complications.

In addition, when immersed (especially bone) osteosynthesis, wire cerclage is usually not used for provisional fixation of bone fragments during the operation, which reduces the quality of osteosynthesis and increases its invasiveness. This is caused by the complexity of adequate reposition and retention of bone fragments using bone holders or Mikulich clamps during surgery. So when installing the plate on the associated bone fragments, the latter are held in a repositional position by the bone holders or clamps, which have to be shifted for this, which, as a rule, leads to a secondary displacement of the bone fragments. To prevent loss of reposition of matching bone fragments when shifting bone holders, Kirschner provisional spokes are often used, drawn through bone fragments and removed after installation of the plate and holding screws. However, this may be associated with a weakening of the perforated bone, its frequent burns in the places of the needles, subsequent suppuration and a decrease in osteogenic potentials, the complexity of removing the spokes after performing bone osteosynthesis (since the installed plate can block their removal), impaired accuracy and quality of bone osteosynthesis - due to the fact that the spokes can interfere with the optimal position of the plate on the bone and the drilling of the bone for holding screws.

In addition, the use of massive bone holders to hold bone fragments in itself is associated with the need to increase the length of skeletonization of bone fragments and, accordingly, reduce their vascularization by worsening regeneration conditions, increasing the depth of the surgical wound and the degree of stretching of soft tissues. The latter circumstance, along with worsening conditions for subsequent wound healing, increases the risk of iatrogenic intraoperative neuritis, such as traction radial nerve neuritis, which is often a formidable complication of humerus bone osteosynthesis.

Therefore, along with the ability to fix bone fragments with an oblique, spiral and longitudinal fracture lines or when fixing a bone fragment to its bed, the prototype device has the following disadvantages:

- alternative stability of fixation of bone fragments and ischemic disorders under the wire, due to the degree of twist of the ends of the wire;

- the need for additional surgery to remove cerclage - 1.5-2 months after immersion osteosynthesis;

- the use of wire cerclage, as a rule, only as the final fixation of bone fragments during immersion osteosynthesis. Not using it for provisional fixation of bone fragments, especially with bone osteosynthesis, reduces the quality and increases the morbidity of osteosynthesis. This is due to the difficulty of adequate reposition and retention of bone fragments during osteosynthesis only by bone holders and clamps, in particular when installing a metal plate and screwing in screws. When shifting bone holders and clamps, a secondary displacement of bone fragments occurs with the need for their repeated reposition;

- the use of only bone holders and clamps to retain bone fragments is associated with a forced increase in the length of skeletonization and a decrease in vascularization of bone fragments, as well as the risk of iatrogenic neuritis.

The purpose of the invention is to increase the effectiveness of the treatment of patients with fractures of long tubular bones, namely for immersion osteosynthesis of oblique, longitudinal and comminuted fractures.

SUMMARY OF THE INVENTION

A device for bone osteosynthesis of long tubular bones, made of cerclage wire, is proposed. This device (Fig. 2, a, b) is characterized in that the wire with a diameter of 1 mm (1) has a length of 90 to 140 mm and for 2/3 - 3/4 of its length in the center (2) and at the ends ( 3) it is flattened and has a width of 1.5-2.0 mm and a thickness of 0.5-0.7 mm, and there are transverse dents (4) on the concave side of the central portion (2) of the wire.

A device is made as follows. The wire for osteosynthesis (Fig. 3, a) with a diameter of 1 mm (1) is fragmented with pliers into several separate segments, from 90 to 140 mm long. Each of these pieces of wire (Fig. 3,) for 2/3 - 3/4 of the length, in the center (2) and at the ends (3), flatten with a hammer on the anvil in one plane. In this case, the flattened sections of the wire have a width of 1.5-2.0 mm and a thickness of 0.5-0.7 mm. Then, shallow dents (4) are formed on the concave side of the flattened central portion of the wire (2) by impacts of a pointed hammer head or by the lower edge of the flat part of the hammer hammer (when the flat part of the hammer hammer is inclined rather than perpendicular to the impacts). The devices made in this way (Fig. 2, b) are sent for sterilization to the operating room so that they are used as necessary, thereby expanding the range of tools for immersion osteosynthesis.

The device is used both as a provisional and final fixation of bone fragments during immersion osteosynthesis. For provisional fixation of bone fragments during bone osteosynthesis, the device is used as follows. After reposition of bone fragments held manually by clamps or bone holders, one or two of the pre-prepared devices, representing a cerclage wire with a diameter of 1 mm, a length of 90-140 mm, for 2/3 - 3/4 of its length in the center and at the ends flattened and having a width of 1.5-2.0 mm and a thickness of 0.5-0.7 mm, and on the concave side of the central portion of the wire having transverse dents, one of the ends is planted behind the bone - above or below it - and around the circumference the bone is brought back (Fig. 4, a). The flattening of the ends of the device allows you to technically facilitate this manipulation, since the flattened end of the device penetrates more easily between the bone and periosteum than the end of a round wire. Then the ends of the device start for each other and perform their twisting with pliers (Fig. 4, b). In this case, the spin nodule can be positioned higher or lower along the perimeter of the skeletonized portion of the circumference of the associated bone fragments, so that it does not appear under the bone plate of the metal structure. As the degree of twist of the ends of the device increases, the mutual adaptation of bone fragments increases. After achieving adequate fixation stability of the latter, the bone holders or clamps are removed, the plate is placed on the bone (Fig. 4, c) and typical osteosynthesis is performed: holes are drilled into the bones into which the screws are screwed (Fig. 4, g). The osteosynthesis margin of safety with a plate with screws, many times exceeding the biasing forces on the bone fragments, makes it unnecessary to leave wire cerclages that are removed. To do this, on one of the two sides of the twist knot, use wire cutters or Liston's tongs to bite the wire and remove the device by pulling the twist knot. When using a hard clamp or pliers, removing the spent device is usually not difficult, but if they suddenly arise, you can turn the screw half a turn and screw it back after removing the device.

When using the device as the final fixation of bone fragments during immersion osteosynthesis, if there are doubts about the stability of the bone osteosynthesis during a multi-fragmented fracture due to the removal of the device, it is left by biting the excess wire twist and bending its nodule to the bone next to the plate (Fig. 4, d).

Device application example

As an example of the application of the proposed device, the following observation. Patient A., 29 years old, was admitted to the Republican Orthopedic and Traumatology Center (ROTC) in Makhachkala on 3.11.16 with a diagnosis of Closed comminuted fracture of the lower third of the right humerus with displacement of fragments. From the anamnesis: injury when falling from the stairs an hour before admission. Under local anesthesia, an attempt was made to reposition the fragments in a closed manner with the application of a gypsum plaster over the Turner. On the control roentgenograms, the displacement remains (Fig. 5, a, b), in connection with which, on November 8, 16, the operation was performed as planned: bone osteosynthesis with a screw plate. In the patient’s position on the back with the right upper limb allotted, a longitudinal skin incision was made along the outer surface of the right shoulder 11-12 cm long - from the level of the middle third of the shoulder down, not reaching the external epicondyle. Subcutaneous tissue and fascia are dissected. In a sharp and blunt way, the incision is deepened between the head of the biceps and brachial muscle to bone fragments - the main fragments and an intermediate fragment of 7-8 cm in length. The fracture plane of the bone fragments was cleaned and freed from the soft tissue interponate, and the fragments were repaired by holding the bone holder. In this case, a prefabricated and sterilized device for bone osteosynthesis of long tubular bones was used, which is a wire for cerclage, characterized in that the wire, with a diameter of 1 mm, a length of 120 mm, and for 2/3 of its length in the center and at the ends, is flattened and having a width of 1.7 mm and a thickness of 0.6 mm, and there were transverse dents on the concave side of the central portion of the wire. The device was used as a provisional fixation of bone fragments as follows. After reposition of the bone fragments held by the bone holders, the device was brought in one of the ends behind the bone and brought back around the circumference of the bone, and its ends were twisted together by pliers. As the degree of twisting of the ends of the device increased, the mutual adaptation of repaired bone fragments intensified. Then the bone holders were removed, and the secondary displacement of the bone fragments did not occur. One 3.5 mm cortical screw was perpendicular to the fracture plane outside the plate from front to back, for which a canal was drilled with a 2.7 mm drill. Then, on the outer surface of the bone, a simulated 120-mm eight-hole LC-DCP plate with eight holes was laid, holes were drilled with a 3.2-mm drill, and six 4.5-mm screws were tightly screwed, the ends of which protrude from the bone by no more than 5 mm. The strength margin of osteosynthesis allowed to do without leaving the device, which was removed. To do this, on one side of the twist knot, cut the wire with wire cutters and pulled the device with pliers for the twist knot. The wound was washed with antiseptic solutions and sutured in layers, leaving perforated tubular drainage. Osteosynthesis is stable and consistent. Upon withdrawal of the patient from anesthesia, active movements with the hand - in full (taking into account the nature and level of fracture and osteosynthesis in the projection of the radial nerve). An aseptic dressing was applied to the wound and a Turner plaster cast on the right upper limb. On the control radiograph, the position of the bone fragments is satisfactory (Fig. 5, c). The postoperative wound healed by primary intention. The patient was discharged for outpatient treatment on 11/17/16. The result of treatment is regarded as good.

Signs of the invention, distinctive from the prototype:

- the presence of several pre-prepared devices with a length of 90 to 140 mm, a round wire diameter of 1 mm, a flattened part width of 1.5-2 mm and a thickness of 0.5-0.7 mm;

- a combination of a circular and flat section of the device along its length;

- the presence of flattened ends of the device;

- the presence of shallow indentations on the inner surface of the flat part of the wire formed by impacts of a pointed hammer head or by the lower edge of the flat part of the hammer hammer (when the flat part of the hammer hammer is inclined rather than perpendicular to it when it hits a flattened wire);

- the presence of a bend in the wire cerclage, the curvature of which is perpendicular to the flattened part of the device.

The technical result (advantages over the prototype) of the device for bone osteosynthesis of long tubular bones:

- the presence of several pre-prepared cerclages facilitates and reduces the time for performing intraoperative manipulation and the entire operation of immersion osteosynthesis;

- the combination of a circular cross-section of wire cerclage (for twisting) and flat cross-section (for circular pulling together without excessive pressure under the wire) determines its rationality - with better handling properties and greater efficiency with less material consumption;

- the presence of a flat part of the cerclage wire causes a decrease in the load per unit area of the bone when tightening the cerclage, which minimizes the main drawback of wire cerclage - the likelihood of bone ischemia under it;

- the presence of shallow impressions on the inner surface of the flat part of the wire, causing it to “have little contact”, also prevents the likelihood of bone ischemia under cerclage;

- the flattened ends of the wire cerclage make it easier to insert them behind the bone, thereby reducing the length of the skeletonization of bone fragments and minimizing their ischemia;

- the possibility of using the device both for provisional reposition and fixation of bone fragments (without leaving it in the postoperative period when performing bone marrow osteosynthesis with a plate and screws), and for the final fixation of bone fragments;

- the exclusion of loss of reposition of bone fragments during the implementation of bone osteosynthesis with a plate and screws, which usually occurs when transferring bone holders or Mikulich clamps to establish a bone plate on repaired bone fragments. Loss of reposition occurs due to the pronounced leverage properties of bone fragments, due to the traction of the muscles of the damaged segment of the limb attached to them, and leads to a delayed operation, trauma to bone fragments and soft tissues and an increased risk of postoperative complications;

- the possibility of reducing the length of the surgical wound and the degree of stretching of the soft tissues, in addition to improving the conditions for their subsequent healing, reduces the risk of iatrogenic traumatic neuritis, for example, traction radial nerve neuritis, which is often a formidable complication of bone osteosynthesis of the middle and lower third of the humerus;

- the absence of the need for provisional holding of needles through repaired bone fragments to prevent the loss of their reposition. Carrying spokes through bone fragments is associated with weakening of the perforated bone, with frequent bone burns at the places of the spokes, fraught with suppuration and a decrease in osteogenic potentials, the complexity of their extraction after performing bone osteosynthesis (an installed plate can block their removal), impaired accuracy of performing bone osteosynthesis, from - due to the fact that the spokes can interfere with the optimal position of the plate on the bone, drilling the bone and holding screws;

- the absence of the need to hold bone fragments in a repositional position during drilling and screwing the screws into the plate frees the assistant’s hands, reduces the surgical trauma and risk of subsequent complications, and also improves the quality of osteosynthesis due to better conditions for modeling and placing the plate on the bone, drilling holes, cutting tapping and holding screws;

- no need to find material for the manufacture of the device, because wire for osteosynthesis is included in the range of tools for submersible osteosynthesis.

Thus, the proposed device can significantly improve the quality of immersion osteosynthesis of long tubular bones and create optimal conditions for wound healing and fracture consolidation in these patients.

Information sources

1) Boychev B., Conforti B., Chokanov K. Operative orthopedics and traumatology. - 2nd ed., Revised. and add. - DI "Medicine and physical education", - Sofia, 1958 - 832 p .;

2) Osteosynthesis / Guide, ed. S. S. Tkachenko. - L .: Medicine, 1987 .-- 272 p .;

3) Movshovich I.A. Operative orthopedics: (Manual for doctors). - 2nd ed., Revised. and add. - M .: Medicine, 1994 - 448 p .;

4) Muller M.E. Guide to internal osteosynthesis: Transl. With him. / M.E. Muller, M. Allgover, R. Schneider, H. Willinger. - 3rd ed., Ext. and add. - M.: Publishing house AdMarginem, 1996 .-- 750 p .;

5) Traumatology: national leadership / ed. G.P. Kotelnikova, S.P. Mironova. - M .: GEOTAR-Media, 2008 - 808 p .;

6) Nabokov A.Yu. Modern osteosynthesis / A.Yu. Nabokov. - M .: Medical Information Agency LLC, 2007. - 400 p. - prototype device.

Claims (1)

A device for osseous osteosynthesis of long tubular bones, which is a wire for cerclage, characterized in that the wire with a diameter of 1 mm has a length of 90 to 140 mm and for 2/3 - 3/4 of its length in the center and at the ends is flattened and has a width 1.5-2.0 mm and a thickness of 0.5-0.7 mm, and on the concave side of the Central section of the wire there are transverse dents.

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