RU2712007C1 - Method of fracture recovery of 3-4 types of bottom plate of ii-iv metatarsophalangeal joints of foot - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, foot surgery, and can be used for restoration of rupture of 3-4 types of plantar plate of II-IV metatarsophalangeal foot joints. Method of recovering a rupture of type 3-4 of the plantar plate of II-IV metatarsophalangeal foot joints involves access on the foot surface of the foot, removal of tendons of long and short finger flexor to side, installation of corrected finger in position 5°–10° of plantar flexion. Bottom of the plantar aponeurosis is separated. Rectangular flap of the extracted bottom of the plantar aponeurosis is cut out, preserving its distal attachment. Flap is brought down to the metatarsophalangeal joint of the corrected finger and the distal portion of the flap is transosteally fixed to the base of the proximal phalanx of the corrected finger. Cranial portion of the flap is then sutured to the proximal portion of the plantar plate, thereby restoring the integrity of the plantar plate.EFFECT: method provides restoring the anatomical integrity of the plantar plate at type 3-4 ruptures by using a flap of the bottom of the plantar aponeurosis, which has a type-specific histological structure with a plantar plate; reduction of traumatism due to absence of additional trans-articular fixation, which leads to reduction of risk of infection, time of operation, period of hospital stay and length of postoperative rehabilitation treatment.1 cl, 1 ex, 4 dwg

Description

A method of repairing the gap 3-4 type of the plantar plate II-IV metatarsophalangeal joints of the foot.

The invention relates to medicine, namely to traumatology and orthopedics, foot surgery, and can be used to repair the gap 3-4 type of the plantar plate II-IV metatarsophalangeal joints of the foot.

A known method of repairing a fracture of the sole plate of the metatarsophalangeal joint of the second finger (Blitz NM, Ford LA, Christensen JC, Plantar Plate Repair of the Second Metatarsophalangeal Joint: Technique and Tips, Foot and Ankle Surgery, vol. 43, number 4, page 266-269, july / august, 2004) which consists of plantar access, a longitudinal skin incision is made under the second metatarsophalangeal joint around the head of the second metatarsal bone with the transition to the base of the second finger. Subcutaneous fat is then dissected. The cover of the tendon holder is cut longitudinally and the tendons of the long and short finger flexors are pulled to the side, thereby accessing the plantar plate. “Simple” tears are restored by applying an eight-shaped suture with an absorbable thread 2-0 or A 3-0 using an atraumatic pricking needle. For complex or large tears, the damaged area of the plantar plate is cut off with a rectangular flap, followed by suturing of the defect. Then carry out transarticular fixation of the second finger with Kirschner spoke for 6 weeks. The postoperative wound is sutured with wide vertical mattress sutures through all layers.

The disadvantages of this method are that the method is limited in application, since it cannot be used for ruptures of the plantar plate of type 3-4 due to the fact that it does not allow to restore the anatomical integrity of the plantar plate. The risk of repeated tearing of the plantar plate is high, since the affected part of the plantar plate is excised and removed, and when the remaining tissue is sutured, tissue tension occurs, which leads to a violation of the biomechanics of the metatarsophalangeal joint, stiffness and limitation of extension of the toe. The use of additional transarticular fixation increases the morbidity and leads to a high risk of infectious complications and long-term recovery treatment in the postoperative period.

A known method of repairing a fracture of the sole plate of the metatarsophalangeal joint of the small toes (Jeffrey E., Christopher F., Direct Plantar Plate Repair Technique, Foot and Ankle Specialist, vol. 6, number 8, page 446-450, december, 2013), which consists in that the patient is laid on his back, a hemostatic tourniquet is applied to the operative limb. Arthroplastic resection or arthrodesis of the proximal interphalangeal joint is performed. Next, a Kirschner needle of 0.062 inch or an 18-gauge needle is percutaneously passed through the metatarsophalangeal joint in the dorsum-plantar direction to mark the metatarsophalangeal joint. Then perform plantar curved access over the metatarsophalangeal joint, cut through the skin, subcutaneous fat. For better visualization, a retractor is installed. The vagina of the flexor tendon retainer is dissected parallel to the tendons, and the tendons are pulled to one side. The plantar plate is visualized, an assessment is made, the degree of damage to it. Finger transarticular fixation is performed in the position of small plantar flexion in the metatarsophalangeal joint. Next, the plantar plate is excised perpendicular to the head of the metatarsal bone and the base of the proximal phalanx and a wedge of 2 to 3 mm is removed. Two side seams are placed on the plantar plate with a non-absorbable thread No. 0 or 2 with a UR-6 pricking needle or similar needle with a small diameter. After this, the postoperative wound is sutured in layers with absorbable suture materials and non-absorbable sutures for the skin. Immobilization with a polymer bus for 1 week. Then unload the front of the foot by walking in a specialized boot for 3 weeks. The Kirchner needle is removed after 4 weeks, after which the patient is allowed a weight load in comfortable shoes.

The disadvantages of this method are that the method is limited in application, since it cannot be used for ruptures of the plantar plate of type 3-4 due to the fact that it does not allow to restore the anatomical integrity of the plantar plate. The risk of repeated tearing of the plantar plate is high, since the affected part of the plantar plate is excised and removed, and when the remaining tissue is sutured, tissue tension occurs, which leads to a violation of the biomechanics of the metatarsophalangeal joint, stiffness and limitation of extension of the toe. The use of additional transarticular fixation increases the morbidity and leads to a high risk of infectious complications and long-term recovery treatment in the postoperative period.

A known method of repairing a rupture of a plantar plate (Donegan Rj, Caminear D., Anatomic Repair of Plantar Plate With Flexor Tendon Sheath Reinforcement, Foot and Ankle Specialist, vol. 20, number 10, page 1-6, 2016), adopted for the prototype, which lies in the fact that they perform L-shaped access on the plantar surface in the first intertarsal space with a transverse transition along the metatarsal fold. Cut the skin, subcutaneous fat, carry out the allocation of the tendon retainer of the flexor of the toe. The retainer is cut longitudinally with the formation of equal medial and lateral parts. The tendons of the short and long finger flexors are retracted medially, exposing the plantar plate. Rupture of the plantar plate is sutured with A 2-0 Fiberwire suture material (Arthrex, Naples, FL). Then, arthrodesis of the proximal interphalangeal conjugation and transposition of the long flexor tendon are performed from the back access. Transarticular fixation of the corrected finger is carried out with a 0.05-inch Kirschner spoke with fixation of the finger in 5 ° -10 ° plantar flexion in the metatarsophalangeal joint. Then re-attach the tendon of the long flexor over the proximal phalanx, proximal to the arthrodesis area. Tighten the gap of the sole plate with a Fiberwire thread and tie. Using a 3-0 PDS thread, both halves of the dissected flexor retainer and the plantar plate are sutured proximal and distal to its fracture. The back and plantar surgical wounds are sutured in layers. Apply an aseptic dressing.

The disadvantages of this method are that the method is limited in application, since it cannot be used for tearing the plantar plate of type 4 due to the fact that the use of the retainer shell does not allow to restore the anatomical integrity of the plantar plate in view of the pronounced tissue deficiency. When using a limited amount of tissue of the finger flexor retainer, there is a high risk of repeated tearing of the plantar plate. The use of additional transarticular fixation increases the morbidity and leads to a high risk of infectious complications and long-term recovery treatment in the postoperative period.

The technical result of the invention is the creation of a method free from the above disadvantages.

The specified technical result is achieved by the fact that the method of repairing the gap 3-4 type of the plantar plate II-IV metatarsophalangeal joints of the foot includes access along the plantar surface of the foot, removal of the tendons of the long and short flexors of the finger to the side, setting the corrected finger to the position 5 ° -10 ° of the plantar flexion, secrete the foot of the plantar aponeurosis, cut out a squared flap from the selected pedicle of the plantar aponeurosis, preserving its distal attachment, the flap is reduced to the metatarsal govomu corrected finger joint and is carried transossalnuyu fixing the distal portion of the flap to the base of the proximal phalanx of thumb corrected, then sutured cranial flap portion to the proximal portion of the plantar plate, thereby restoring the integrity of the sole plate.

The invention is illustrated by the following graphic materials, where in FIG. 1 is a clinical view of the foot before surgery, FIG. 2 is a radiograph in direct projection before surgery, FIG. 3 is a clinical view of the foot after two stages of the operation, FIG. 4 - clinical view of the foot after the third stage of the operation.

Embodiment

In the patient's supine position after processing the surgical field and applying the squeezing tourniquet to the lower leg with a medical instrument, for example, a scalpel, a linear incision is made along the plantar surface of the foot over the affected metatarsophalangeal joint 3-6 cm long above the head of the metatarsal bone. The skin underlying soft tissues is dissected in layers, the leg of the plantar aponeurosis is secreted, and taken aside. The tendon of the long and short flexors of the finger is abducted, retracted to the medial side, the plantar plate is exposed. A flap of rectangular shape is cut out from a previously selected leg of the plantar aponeurosis 2-3 cm long, while maintaining its distal attachment. Then the flap is brought down to the metatarsophalangeal joint of the corrected finger and transosseous fixation of the distal part of the flap is carried out using a medical instrument, for example, a pricking needle to the base of the proximal phalanx of the corrected finger with medical suture material, for example, Vickryl medical thread 2-0. Then, the corrected finger is placed in the position of 5 ° -10 ° of the plantar flexion and sewn, using a medical tool, for example a pricking needle, the cranial part of the flap to the proximal part of the plantar plate thereby restoring the integrity of the plantar plate. X-ray control is performed, the wound is sutured in layers, an aseptic dressing with figured bandage is applied.

Clinical example.

Patient S., born in 1961 in 2017, was admitted to the FSBI NNIITO named after Y. L. Tsivyan of the Ministry of Health of Russia with complaints of pain and deformity of the forefoot of the right foot. Medical history: Longitudinal-transverse flatfoot has been disturbing for many years. Over the past five years, deformation of the second toe appeared, pain, discomfort in the anterior region of the right foot intensified, and the difficulty of wearing shoes increased. Treatment at the place of residence did not lead to a positive effect. A comprehensive clinical and radiological examination was carried out before the operation (Fig. 1, Fig. 2) and the clinical diagnosis was established: Bilateral longitudinal-transverse flatfoot 2-3 degrees. Hallux valgus bilateralis 3 degrees on the left, 2 degrees on the right. Fixed hammer-like deformation of the second toe of the right foot. Instability of the second metatarsophalangeal joint on the left 3 degrees, rupture of the plantar plate 4 type. Left-sided metatarsalgia syndrome. Next, a phased surgical treatment was performed. In the first and second stages, operations “Lapidus and Akin” were performed to eliminate the deformation of 1 toe of the right foot, and proximal interphalangeal arthrodesis with immersion fixation of the second toe of the right foot (Fig. 3), where it is seen that subluxation of the second toe is preserved, which is caused by a type 4 gap plantar plate. The third stage was the surgical treatment to repair the gap of type 4 of the plantar plate of the metatarsophalangeal joint of the second finger by our proposed method. After performing the method, a snapshot of the general view of the foot is taken (Fig. 4), which shows that the second finger is installed in the anatomically correct position, which is achieved by restoring the plantar plate. After 12 months, a control examination of the patient was performed. The patient does not complain. Notes the absence of pain, restoration of biomechanics of the metatarsophalangeal joint and, as a result, an increase in the range of motion of the fingers of the right foot. The patient is satisfied with the results.

The advantages of the proposed method compared to the existing ones are that the method is applicable for ruptures of the plantar plate of type 3-4 due to the fact that a flap is used that represents a sufficient amount of tissue. When it is fixed, there is no tissue tension, which leads to restoration of the biomechanics of the metatarsophalangeal joint, to the absence of stiffness and limitation of extension of the toe, and as a result, the risk of developing repeated rupture of the plantar plate is reduced. The method allows to restore the anatomical integrity of the plantar plate with type 3-4 ruptures, since a flap from the pedicle of the plantar aponeurosis is used, which has a type-specific histological structure with the plantar plate. The inventive method is less traumatic, since there is no additional transarticular fixation, which reduces the risk of infection, the time of surgery, the period of hospital stay and the duration of rehabilitation treatment in the postoperative period.

The method for repairing the 3-4 type gap of the plantar plate II-IV of the metatarsophalangeal joints of the foot is implemented using modern equipment, using modern technologies and materials.

Claims (1)

A method for repairing a gap of type 3-4 of the plantar plate II-IV of the metatarsophalangeal joints of the foot, including access along the plantar surface of the foot, removal of the tendons of the long and short flexors of the finger to the side, setting the corrected finger in the 5 ° -10 ° position of the plantar flexion, characterized in that the foot of the plantar aponeurosis is isolated, a squamous flap is cut out from the distinguished foot of the plantar aponeurosis, maintaining its distal attachment, the flap is brought down to the metatarsophalangeal joint and carried on the finger transossalnuyu fixing the distal portion of the flap to the base of the proximal phalanx of thumb corrected, then sutured cranial flap portion to the proximal portion of the plantar plate, thereby restoring the integrity of the sole plate.

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