RU2698087C1 - Method for substitution of tibialis bone posttraumatic defect with soft tissue defect - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, and can be used for substitution of posttraumatic defect of tibia with presence of soft tissue defect. Method involves fixation of bone fragments with the help of an external fixation apparatus, performing osteotomy of one of the fragments and movement of the created free fragment with the apparatus into the defect region until contact and adhesion with the opposite fragment with formation of an elongating bone regenerate in the osteotomy area. Soft tissue reserve is simultaneously created over a free movable bone fragment by displacing soft tissues when conducting the wires through the bone fragment, as well as temporary angular displacement of the axis of the bone fragments. In the process of longitudinal and rotational movement of the fragment, the compressed granulation and scar tissue areas are dosed out and extruded to the dense one at the maximum possible area of contact of the bone fragments and forming a connective tissue clutch around them with approaching edges of the soft tissue defect for their adhesion. Soft tissues of opposite surfaces of the defect approach each other to contact.

EFFECT: method provides reducing intraoperative injuries and the need for additional surgical interventions, improves blood supply to periosteal callus, increases efficiency of osteosynthesis by preserving granulation tissue.

1 cl, 6 dwg, 1 ex

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 with a soft tissue defect is relevant, since at present it is significantly

the severity of injuries in anthropogenic, man-made and natural disasters increases.

The prior art. There is a method of replacing a pathological section of a long tubular bone when controlled transosseous osteosynthesis of the affected limb segment is carried out (Copyright certificate for the invention No. 1678343 of the USSR, MKI 3A61B 17/00. GA Ilizarov. Method for treating a defect of the tibia with scarred soft tissues, publ. September 23, 1991. Bull. No. 35). 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 fixed with traction knitting needles is performed with the possibility of its metered axial movement towards the defect to replace it and make up the bone length with growing bone callus at the osteotomy site, while its edge adjacent to the changed tissues is resected, its temporary displacement from the latter with subsequent correction of the axis of the segment.

However, the implementation of this method is highly traumatic, technically difficult, and requires additional surgical interventions to close the soft tissue defect and, as a result, there is an increase in the number of adverse treatment outcomes.

The prototype of the proposed method can be a technique for replacing a tibial defect with an autograft from the tibia on a vascular pedicle with a resection of the affected area of the tibia (AkinS., DurakK., 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 rehabilitation of the focus, impaired blood supply in the affected area, and delayed consolidation. 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 problem of eliminating large soft tissue defects seems to be complex.

The present invention is to develop a method for replacing a post-traumatic defect of the tibia with the presence of a soft tissue defect that does not require complex technical design, which allows to reduce the invasiveness of the operation and the need for additional surgical interventions.

Significant differences: The method is carried out in that a fragment of one of the fragments of the tibia is mobilized, its metered displacement into the defect zone before contact and fusion with the opposite fragment, characterized in that metered compression and extrusion of the granulation and scar tissue up to dense on the maximum possible area of contact of bone fragments and the formation of a connective tissue sleeve around them. In this case, the soft tissues of the opposite surfaces of the defect come closer to contact.

A diagram of the implementation of the method is presented in FIG. 1A, 1B, 1B, 1G.

The novelty of the invention lies in longitudinal and rotational compression with extrusion of granulation and scar tissue to a dense contact area of bone fragments on the maximum possible area and the formation of a connective tissue sleeve around them. Surgical excision of tissues in the area of the bone defect, processing of bone fragments is excluded, which significantly reduces tissue trauma in the area of osteosynthesis, the formation of a connective tissue sleeve from scar and granulation tissue around the contact area of bone fragments strengthens the formed periossal bone callus and is an additional source of its blood supply. Along with reducing the depth of the soft tissue defect due to the movement of tissues from the interposition zone, the approach of the edges of the defect is carried out due to the displacement of the soft tissues before the spokes and the angular displacement of the adjacent bone fragments.

The method is as follows.

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 held outside the area of the bone defect. In the tensioned state, the spokes are mounted on the apparatus supports installed at the appropriate level, which are interconnected by threaded rods. In the projection of the affected area of the tibia, the defect is accessed and non-viable tissues in the focus are removed. When carrying knitting needles in the process of fixation by the apparatus, soft tissues are displaced towards the defect. The creation of their primary supply prevents the eruption of soft tissues when moving bone fragments and helps to close the defect. Outside of the soft tissue defect and outside the area of granulation and scar tissue, an osteotomy of a bone fragment is performed for its metered movement (Fig. 1B, Fig. 4). When applying an external fixation apparatus to a limb segment, it is advisable to give the position of angular deformation from the side of the soft tissue defect with the apex corresponding to the center of the bone defect. Formed deformation provides the convergence of opposite surfaces of the soft tissue defect at the site of interposition between bone fragments. The operation ends with suturing, control radiography and stabilization of the apparatus.

From 7-8 days after the operation, a metered movement of the bone fragment separated by an osteotomy in the area of bone diastasis is performed within 0.5-1.0 mm per day in the direction of the end of the opposite fragment. During fragment displacement, granulation and scar tissue are gradually compressed between fragments, which leads to their gradual extrusion from the position of interposition. Granulation and scar tissue are displaced to the lateral surfaces of the displaced fragment, forming around it a soft tissue case covering the junction of bone fragments. Through the longitudinal and rotational movement of the mobilized bone segment, contact is achieved between the maximum possible area of contact and congruence of bone fragments. The device is put into fixation mode until complete organotypic restructuring of the bone regenerate. In cases of creating a deformation of the segment to bring the edges of the soft tissue defect closer, when the movable fragment is contacted with the end of the opposite fragment, the biomechanical axis of the operated limb segment is restored by the external fixation device (Fig. 1B, Fig. 5). The adhesion strength is controlled by clinical testing and radiological. After dismantling the device, the patient is prescribed a course of exercise therapy (Fig. 1G, Fig. 6).

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

Patient S., 39 years old, was admitted 30 days after a road accident, at the time of which he received a 10 cm long defect of the lower leg bones with a soft tissue defect, with bone fragments protruding from it, complicated by post-traumatic osteomyelitis.

An operation was performed to remove non-viable bone fragments and areas of soft tissue, purulent contents, and osteosynthesis with an external fixation device. When carrying knitting needles in the process of fixation by the apparatus, soft tissues were displaced towards the defect. To replace the defect of the tibia, an osteotomy of the distal fragment of the tibia was performed. When applying an external fixation apparatus to a limb segment, the position of the angular deformation with the vertex corresponding to the center of the defect was attached (Figure 2). From the eighth day after the operation, metered distraction of bone fragments in the osteotomy area was carried out within 0.5 mm per day. The distraction lasted 111 days. During the movement of the fragment during the gradual compression of granulation and scar tissue, they were pressed in the zone of interposition. Granulation and scar tissue shifted to the lateral surfaces of the transferred fragment, forming around it a soft tissue case covering the junction of the bone fragments. Having reached the contact of the movable bone fragment with the end of the opposite fragment, the biomechanical axis of the lower leg was restored by the external fixation apparatus, and the apparatus was put into fixation mode until complete organotypic reconstruction of the bone regenerate. The fixation period was 136 days. Before removing the apparatus, the adhesion strength was monitored by clinical examination and radiological. After its dismantling, the patient underwent a course of exercise therapy (Figure 3).

The developed method can be used for all variants of controlled transosseous osteosynthesis, where it is required to compensate for a post-traumatic defect of the tibia with the presence of a soft tissue defect, including a complicated purulent infection.

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

Information sources

1. Ilizarov G.A.A.S. 1678343 USSR, MKI 3A61V 117/00. A method for treating a tibial defect in scarred soft tissues, published on September 23. 1991. Bull. No. 35).

2. Akin S., Durak K., One-stage treatment of chronic osteomyelitis of the proximal tibia using a pedicledvascular ised 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 replacing a post-traumatic soft tissue and tibia defect, including fixing bone fragments using an external fixation apparatus, osteotomy of one of the fragments and moving the created free fragment to the defect until contact and fusion with the opposite fragment with the formation of an elongated bone regenerate in the osteotomy region, characterized the fact that at the same time a reserve of soft tissues is created over a free movable bone fragment by displacement of soft tissues during spokes through the bone fragment, as well as the temporary angular displacement of the axis of bone fragments, and in the process of longitudinal and rotational movement of the fragment, metered compression and extrusion of the area of granulation and scar tissue to a dense at the maximum possible contact area of the bone fragments and the formation of a connective tissue coupling around them edges of the soft tissue defect for their fusion.

Images