RU2699533C1 - Method of surgical management of heel bone fracture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology, and can be used for treating heel bone fractures with displacement of fragments. Surgical treatment of calcaneal bone fracture is performed by fragment reduction and fixation in external fixation apparatus (EFA). At that, through the soft tissue puncture in the back to the anterior tuberosity, a reducting Schantz screw is introduced in the back, and reposition is performed, simultaneously performing the following procedures: restoration of the calcaneal bone axis by traction of the introduced screw in the sagittal plane, wedging of the fragments by swinging motion of the calcaneal tuberosity and calcaneal bone width recovery by pressure on it from lateral and medial surfaces. It involves inserting three fixing screws of Shantz into the shin bone on the side of its anterior inner surface without going out into the soft tissues on the other side of the shin bone. Screws are placed at the level of the lower and middle one-third of the tibia. EFA is assembled by jointing re-fixing and fixing screws with three bars to form a triangle. Reinforcing screw is fixed to one of triangle tops while remaining screws are secured to triangle opposite to said vertex.

EFFECT: method provides simultaneous reduction of traumatism, prevention of suppurative complications, possibility of early load on postoperative extremity, achieving anatomical reduction with eliminating valgus displacement and calcaneal bone shortening, due to strong fixation in ANF and access to soft tissues in early postoperative period.

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Description

The invention relates to medicine, namely to traumatology, and can be used to treat calcaneus fractures with displacement of fragments.

Calcaneal fractures represent a fairly common group within all injuries of the foot. At the same time, it is far from always possible to achieve a good functional result due to untimely treatment due to severe soft tissue edema, is conflicting and, in some cases, the patient’s serious general condition. An open reduction entails a risk of wound complications (suppuration, prolonged wound healing, flap necrosis). This is due to the peculiarities of operative access to the calcaneus and meager blood supply to the skin flap. The search for optimal methods for the treatment of calcaneal fractures with displacement of fragments with the possibility of accurate reposition, firm fixation and lower risks of postoperative complications continues to be relevant.

There is a method of treating intraarticular calcaneus fractures using reposition and fixation with cannulated screws (RU 2484785, C2). The main advantage of the method is its minimally invasiveness. Through an incision of up to 1.0 cm and a puncture of the skin, instrumental reposition of calcaneus fragments is performed under the control of electron-optical (EOP) imaging, secondly, through punctures of the skin, it is pulled together and fixed with a cannulated spongy compression screw with a diameter of 4.0 mm, fragments containing articular surfaces are pulled together and fix the fragments of the calcaneal tuber cannulated compression screws with triple thread diameters of 6.0 mm and 4.0 mm. Then, an internal rigid calcaneal skeleton is created by longitudinally guiding cannulated compression screws with a triple thread 6.0 mm in diameter through the entire calcaneus: through the region of the subchondral layer of the posterior articular surface in the upper section and parallel to the lower surface of the calcaneus. In case of a fracture of the anterior calcaneus, the guide needles are passed through the calcaneo-cuboid joint and left until the fracture is consolidated, after which they are removed. The use of this method involves repeated surgical treatment in order to remove the screws after a while, and the introduction of compression screws leads to a shortening of the calcaneus.

There is a method of treating closed "tongue-like" calcaneal fractures with displacement of bone fragments, which is characterized by the use of reposition and the use of a Shants screw or awl (Essex-Lopresti) and knitting needles with its subsequent fixation in an external fixation device (ANF) or through bone osteosynthesis (M. E. Kupitman et al. Justification of a new method for closed reposition of calcaneus fractures. "Traumatology and Orthopedics of Russia", 2012, No. 4 (66), pp. 99-104). This method using ANF is a big inconvenience for the patient because of its size during the rehabilitation period.

There is a method of treating calcaneus fractures (RU 2238051, C1), which consists in open reposition using a device, which is a lever, on the shaft of which a movable grip equipped with a screw lock is installed. However, this open reposition leads to an increase in the risk of complications, and the features of this device lead to the need for its separate production.

A known method for the surgical treatment of calcaneus fractures with a spoke apparatus (RU 2321369, C1), which consists in applying an apparatus containing a base annular support. The disadvantages of this method include the large size of the apparatus, its large weight, the complexity of early activation and a high risk of complications.

There is a method of surgical treatment of comminuted calcaneus fractures with the installation of the plate directly on the bone after open reduction. The use of this fixative is accompanied by prolonged healing of the postoperative wound and a high probability of purulent complications, which negatively affects the fracture fusion and the rehabilitation period, in addition, the fixative must be removed after consolidation of the fracture (Zwipp N. - “Clin Orthop Relat Res.”: Osteosynthesis of displaced intraarticular fractures of the calcaneus, 1993, (290) c. 76-86).

The “Axial fixation” method is used (Essex - Lopresti surgical technique) (Calcaneal fractures. // Margo Anterior. - 2000, No. 1-2. - S. 1-8), which is based on the installation of large diameter Steinmann rods or Gissan's nail, with the help of which the bone fragment is repositioned, followed by the application of a plaster cast on the lower limb, while the outer part of the rod is fixed in a plaster cast. The disadvantage of this method is the large size of the locking device, the lack of early activation and the risk of suppuration of the places of introduction of the clamp.

A method for the treatment of calcaneus fractures (RU 2463011, C1) is described, in which ANF is applied together with transosseous osteosynthesis. Two crossed needles are carried through the middle and lower third of the lower leg. The spokes are fixed in the ring supports, which are interconnected by means of rods. A transosseous fixator in the form of a hook rod is introduced into the fragment of the calcaneus through the lower edge of the calcaneal tuber from the side of the plantar surface of the foot. The hook rod is fixed in the through hole of the support holder of the reposition unit. Spoke to protect the ankle joint from overextension during reposition through the front section of the talus bone, the needle is fixed in a semicircle. Dose reduction of fragments in the postoperative period is carried out. After achieving a complete reposition of the fragments, they are fixed by introducing into the calcaneus through the upper edge of the calcaneal tuber and the fracture line of the cannulated screws. The use of this method involves the use of a bulky design that worsens the quality of life of the patient during the rehabilitation period, and requires daily reposition in the early postoperative period.

A known method of minimally invasive treatment of calcaneus fractures (RU 2440046, C1), including reposition of the fracture using a 6.5 mm rod-screw or Shants screw. The rod is introduced from the calcaneal tuber side through the calcaneus to its anterior section in the direction of the plane parallel to the calvar-calcaneal joint, the fixation of the fragments is carried out by cannulated screws, carried out randomly in compression mode. This method is easy to use, however, when using large-diameter screws, a high degree of occurrence of fragment splitting, the risk of complications due to the pressure of the screw head on soft tissues; screw fixation in compression mode shortens the calcaneus, and arbitrary insertion of screws can lead to unstable fixation.

There is a method for minimally invasive treatment of lingual fractures of the calcaneus with displacement of fragments (RU 2520800, C1) (prototype). The method includes reposition of fragments using a reposition rod and holding spokes for insertion of cannulated screws. After reposition, at least two spokes are inserted to temporarily fix the fragments, and the reposition rod is removed. Then, a biocomposite material in the form of phosphate cement is introduced through its channel until the gap between the fragments is filled along the fracture line. After it hardens, three spokes are used to insert cannulated screws. One spoke is passed through the upper surface of the lingual fragment into the anterior section of the calcaneus, the other through the posterior section of the fragment into the anterior calcaneus. A third spoke is passed through the plantar surface of the posterior calcaneus to the anterior fragment. After that, cannulated screws with a diameter of 4.0 mm are inserted through the mentioned knitting needles, and then all the knitting needles are removed. The disadvantage of this method is the risk of purulent complications, the lack of the possibility of early activation with a load on the limb and the need for additional equipment in the form of a biocomposite material.

The medical-technical result achieved by the implementation of the proposed method is the simultaneous:

- reduction of morbidity, prevention of purulent complications due to the low morbidity of operative access, ease of implementation by eliminating sequential methods of introducing the rod, knitting needles into the calcaneus and removing them from it, using a biocomposite material;

- providing the possibility of an early load on the limb in the postoperative period;

- achievement of anatomical reposition with the elimination of hallux valgus displacement and shortening of the calcaneus;

- ensuring strong fixation in the ANF;

- providing access to soft tissues in the early postoperative period.

The invention consists in the following.

Surgical treatment of calcaneus fracture is carried out by reposition of fragments and their fixation in ANF. At the same time, through the puncture of soft tissues, a Shants repair screw is inserted back to front into the calcaneal tubercle and reposition is performed, simultaneously performing the following techniques: restoring the calcaneal axis by traction for the inserted screw in the sagittal plane, wedging fragments due to the oscillating movements of the calcaneal tuber by the inserted screw and restoration the width of the calcaneus by pressure on it from the lateral and medial surfaces. Three Shants fixing screws are inserted into the tibia from the side of its anterior-inner surface without exiting into soft tissue on the other side of the tibia. Screws are located at the level of the lower and middle third of the tibia. They mount the ANF, connecting the repair and fixing screws with three rods to form a triangle. The reponent screw is fixed to one of the vertices of the triangle, and the remaining screws to the side of the triangle opposite the aforementioned vertex.

The restoration of the axis of the calcaneus can be carried out by traction downward for the retaining screw in the sagittal plane.

The restoration of the width of the calcaneus can be performed by manual pressure on it from the lateral and medial surfaces.

The connection of the fixing and fixing screws with rods can be carried out with the formation of a right-angled triangle, the sides of the right angle of which are the rods holding the screws.

The method is as follows.

During surgical treatment of a calcaneus fracture with displacement of fragments (Figs. 1 and 2), a Schantz repair screw is inserted through the puncture incision into the calcaneal tubercle (Fig. 3 and 4, position 1). The inserted screw is moved in the sagittal plane in order to restore the axis of the calcaneus, at the same time manual compression is performed on both sides of the calcaneus to eliminate lateral displacements and restore the width of the calcaneus, while additionally, the calcaneal tuber is pulled by the screw for wedging fragments.

Under the control of image intensifier tubes, the degree of reposition is evaluated. After reaching a satisfactory position of the calcaneus, the ANF is installed: three Shantz screws with a diameter of 5 mm are used, as well as a Shantz repair screw inserted into the calcaneus and three rods with a diameter of 12 mm, though.

Shants screws are inserted into the tibia in the lower and middle third (Fig. 5, position 2) along the antero-internal surface. The Shants reponent screw is fixed by means of rods (Fig. 5, position 3) to the above. It should be noted that the screws of this unit do not extend beyond the skin on the other side of the limb. Usually, the superimposed ANF forms a figure close to a right triangle. In this case, the right angle will be at the junction of the rods with the screw in the calcaneus. Thus, feint introduced into the tibia is fixed to one rod, this rod is connected to two others with the formation of a triangle. Moreover, in the corner formed by these two rods, a repair screw is inserted into the calcaneus. In other words, the repair screw is fixed to one of the vertices of the triangle, and the remaining screws are fixed to the side of the triangle opposite to the aforementioned vertex.

In the postoperative period, bandaging of screw insertion sites is carried out, activation with crutches. Sutures are removed on the 12-14th day, the metered load on the foot is allowed at the end of 4 weeks, ANF is dismantled at 8 weeks.

Clinical example

Patient K., 39, was injured as a result of an accident as a driver, was examined, a diagnosis was made of a closed tongue-like fracture of the right calcaneus with a displacement (Fig. 6, 7, 8, 9), there were subepidermal blisters, severe swelling of the right foot and heel area. Given the significant displacement of fragments, the unsatisfactory condition of the skin, reposition was performed, fixation of fragments in the ANF by the proposed method, the displacement was eliminated. Fixation in the apparatus for up to 6 weeks with the subsequent transition to the orthosis. The result was evaluated after 1 year; the function was restored (Fig. 10, 11), the patient returned to his previous activity. Evaluation of treatment was carried out on the scales of FFI, AOFAS, SF-36 and MSHTS. For all questionnaires, the result was rated as good.

Using this technique allows axial reposition to be minimally invasive, which is impossible during treatment with spoke-rod and spoke devices, to eliminate the displacement along the length and valgus position of the calcaneus fragments. Fixation by an external device makes it possible to carry out dressings of damaged soft tissues in adjacent areas and provides strong fixation of fragments. These features lead to early activation of the patient and a better treatment result.

According to the claimed method treated 36 patients with fractures of the calcaneus. Of these, good and satisfactory results were obtained in 82% of cases.

Thus, the proposed method has high efficiency and allows you to:

- use the technique in conditions of emergency assistance,

- perform reposition of the calcaneus minimally invasively and relatively quickly,

- sufficiently firmly fix the fragments with an external fixation device,

- provide free access to surrounding soft tissues,

- reduce the time of activation and increase patient satisfaction from treatment.

Claims (4)

1. A method of surgical treatment of a calcaneus fracture, including reposition of fragments and their fixation in an external fixation apparatus, characterized in that through the puncture of soft tissues back to front, a Shants repair screw is inserted into the calcaneal tubercle and reposition is performed, while performing the following techniques: restoration of the calcaneus axis by traction for the inserted screw in the sagittal plane, wedging of the fragments due to the swinging movements of the calcaneal tuber with the inserted screw and restoring the width of the calcaneus by pressure on from the lateral and medial surfaces; then, three Shants fixing screws are inserted into the tibia from the side of its anterior-inner surface without exiting into soft tissues on the other side of the tibia, placing them at the level of the lower and middle third of the tibia, the external fixation apparatus is mounted, connecting the repair and fixing screws with three rods to form of the triangle, while the repair screw is fixed to one of the vertices of the triangle, and the remaining screws are fixed to the side of the triangle opposite the aforementioned vertex. 2. The method according to p. 1, characterized in that the restoration of the axis of the calcaneus is carried out by traction down the inserted screw in the sagittal plane. 3. The method according to p. 1, characterized in that the restoration of the width of the calcaneus is performed by manual pressure on it from the lateral and medial surfaces. 4. The method according to p. 1, characterized in that the connection of the fixing and fixing screws with the rods is made with the formation of a rectangular triangle, the sides of the right angle being the rods that fix the screws.

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