RU2721285C1 - Method of open reduction and fixation of shifted fractures of cotyloid cavity in experiment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, and can be used in methods of open reduction and fixation of shifted acetabular fractures experimentally. Method involves surgical approach, exposing the fragments of an acetabulum, their open reduction with fixation by screws and plates. Corpse is placed on its side; Harding outer-front access to the hip joint is performed, which is used for hip replacement. It involves anterior dislocation of femur. That is followed by femoral neck osteotomy. Hip head is removed, the trochanteric portion of the hip is withdrawn backwards. Further, an acetabular fracture of the B2.2 type according to the AO / ASIF international classification is modeled by osteotomy of the acetabulum with creating column diastase. At the next step, displaced columns of cotyloid cavity approach each other, achieving maximum accurate reposition. That is followed by placing a reposition-fixing support ring into the cotyloid cavity of the corresponding cotyloid cavity so that the first flange is above the upper edge of the cotyloid cavity, and the second flange is located at the junction of the ischial bone and the rear edge of the acetabulum, and the third flange is positioned to confine the front edge of the cotyloid cavity and the horizontal branch of pubic bone. Then the ring is fixed to the articular surface of the main fragment of the acetabulum linked to the iliac bone by inserting the screws through a group of holes of the support ring within the articular surface of the main fragment of the acetabulum. That is followed by successively introducing one screw at an angle into the posterior column through the corresponding opening of the ring and its articular surface, and into the front column through the corresponding opening of the ring and its articular surface, leaving part of each screw above the inner surface of the ring. Further, cotyloid cavity recomposition is continued by pulling the columns behind the screws and creating a mutual compression between the main acetabular fragment related to the iliac bone, posterior and anterior acetabular columns, on one side, and creating mutual compression between the main fragment of the cotyloid cavity, posterior and anterior columns of the acetabulum and a ring on the other side. Then, without loosening the tie-rod by the screws, the latter are alternately screwed into the rear and front columns until the screw head rests against the edges of the ring hole, followed by load on the bone, detecting mobility between the columns and between the columns and the ring. At the next stage screws are introduced into cotyloid cavity columns through all free holes in the ring at different angles, thus strengthening columns fixation to the ring. Then, the ring is additionally fixed to the walls of the acetabulum by inserting screws through the holes of the three flanges.

EFFECT: method provides correct reposition and reliable fixation due to use of fixing support ring, which is attached to cotyloid cavity.

1 cl, 23 dwg

Description

The method of open reduction and fixation of displaced acetabular fractures in an experiment using a reposition-fixation support ring relates to medicine, namely to traumatology for surgical treatment of displaced acetabular fractures, to operative orthopedics, hip arthroplasty, experimental medicine, biomechanics.

For fixing fragments and columns of the acetabulum, various reconstructive plates and screws are used (Fig. 1).

The closest solution to the treatment of displaced acetabular fractures can be achieved using M.E. rings. Muller, Protek and H.B. Burch - R. Schneider (Fig. 2, 3, 4), which allow you to enter screws through existing holes in the wall of the acetabulum. However, these devices do not allow screws to be inserted into the bone mass of the walls of the acetabulum at an acute angle, and the location of the holes for introducing screws does not allow concentrating the fixing forces of various fragments of the acetabulum taking into account the classification of fractures of the acetabulum (Fig. 5) (Muller M.E., Allgover M., Schneider R., Willinger X. Guidelines for internal osteosynthesis. - M., 1996. - 756 p.).

EFFECT: development of a method for open reposition and fixation of displaced acetabular fractures.

The technical result is ensured by the fact that the corpse is laid on its side, external-anterior-frontal Harding access to the hip joint is used, which is used for endoprosthetics of the hip joint, the front dislocation of the femur is performed, then the osteotomy of the femoral neck is performed, the femoral head is removed, the trochanteric part of the femur is brought back. then model the acetabular fracture of type B2.2 according to the international classification AO / ASIF by osteotomy of the acetabulum with the creation of diastasis between the columns, at the next stage, the displaced columns of the acetabulum are brought closer to each other, achieving the most accurate reposition, then set the corresponding acetabulum acetabulum-sized repositionally-fixed support ring so that the first flange is located above the upper edge of the acetabulum, and the second flange is placed at the confluence of the ischium and posterior edge of the acetabulum, and the third flange is installed at the confluence the common edge of the acetabulum and the horizontal branch of the pubic bone, then the ring is fixed to the articular surface of the main fragment of the acetabulum associated with the ilium by inserting screws through the group of holes of the support ring within the articular surface of the main fragment of the acetabulum, after which one screw is inserted sequentially at an angle to the rear column through the corresponding hole of the ring and its articular surface, and to the front column through the corresponding hole of the ring and its articular surface, leaving a part of each screw above the inner surface of the ring, then continue repositioning the acetabulum by pulling the columns by the screws and creating mutual compression between the main fragment of the acetabulum associated with the ilium, the posterior and anterior columns of the acetabulum, on the one hand, and creating mutual compression between the main fragment of the acetabulum, the posterior and anterior columns of the valvular cavity and the ring on the other hand, then, without weakening the thrust for the screws, the latter are alternately screwed into the rear and front columns to the stop of the screw head into the edges of the ring opening, after which a load is applied to the bones revealing mobility between the columns and between the columns and the ring, the next stage, the screws are inserted into the columns of the acetabulum through all free holes in the ring at different angles, increasing the fixation of the columns to the ring, then the ring is additionally fixed to the walls of the acetabulum by introducing screws through the holes of three flanges.

The invention is illustrated by the following figures.

In FIG. 1 shows a photo of the use of a reconstructive plate (1) for fixing a fracture of the pelvic bones.

In FIG. 2 presents a photo of the acetabular reinforcing support ring M.E. Muller (M.E. Muller).

In FIG. 3 shows a photo of the acetabular reinforcing support ring with a hook of the company "Protek", Switzerland (PROTEK)

In FIG. Figure 4 shows a photo of the acetabulum reinforcing ring Burch - Schneider (H.B. Burch - R. Schneider).

In FIG. 5 is a photo of the acetabular B2.2 fracture diagram according to the international classification AO / ASIF. Cross fracture of the acetabulum. Fracture of the posterior column of the acetabulum. Fracture of the anterior column of the acetabulum. 2 - the main fragment of the damaged acetabulum associated with the ilium; 3 - part of the articular surface of the acetabulum; 4 - the back column of the acetabulum; 5 - line fracture of the posterior column of the acetabulum; 6 - line of transverse fracture of the acetabulum; 7 - the front column of the acetabulum; 8 - line fracture of the anterior column of the acetabulum.

In FIG. 6 shows a photo of marking the section along the outer surface of the left trochanteric region.

In FIG. 7 is a photo of a cut of the skin and muscle stretching the fascia of the thigh along the outer surface of the left trochanteric region.

In FIG. Figure 8 shows a photo of modeling on the cadaveric material of an acetabular B2.2 fracture according to the international classification AO / ASIF by osteotomy of the acetabulum with diastasis between the fragments. 2 - the main fragment of the damaged acetabulum associated with the ilium; 3 - part of the articular surface of the acetabulum; 4 - the back column of the acetabulum; 5 - line fracture of the posterior column of the acetabulum; 6 - line of transverse fracture of the acetabulum; 7 - the front column of the acetabulum; 8 - line fracture of the anterior column of the acetabulum; 9 - a large skewer.

In FIG. 9 is a photo of the result of a preliminary open reposition of acetabular fragments using tools. 2 - the main fragment of the damaged acetabulum associated with the ilium; 3 - part of the articular surface of the acetabulum; 4 - the posterior column of the pelvis; 7 - front pelvic column; 9 - a large skewer.

In FIG. 10 is a photo of the installation of the reposition - fixation support ring in the acetabulum with the insertion of a screw into the main fragment of the acetabulum associated with the ilium through one of the holes in the first ring flange. 2 - the main fragment of the damaged acetabulum associated with the ilium; 9 - a large skewer; 10 - the first flange of the ring; 11 - a group of holes in the region of the first and second flanges; 12 - screw; 13 - the third flange of the ring.

In FIG. 11 shows a photo of the screws for fixing the fragments of the acetabulum to the reposition - fixation support ring.

In FIG. 12 is a photo of the insertion of screws into holes in the region of the first flange. 9 - a large skewer; 10 - the first flange of the ring; 11 - a group of holes in the region of the first flange and the second flange (not visible, located under a large skewer); 12 - screw (s).

In FIG. 13 is a photo of the introduction of screws into the anterior and posterior columns of the acetabulum. 2 - the main fragment of the damaged acetabulum associated with the ilium; 4 - the back column of the acetabulum; 7 - the front column of the acetabulum; 9 - a large skewer; 12 - wits.

In FIG. 14 is a photo reposition of the acetabulum using a tool. 12 - vits inserted into the posterior and anterior columns of the pelvis; 14 - a tool for pulling and reposition of fragments.

In FIG. 15 is a photo of the insertion of screws (12) through all the free holes in the ring.

In FIG. 16 shows a photo of additional fixation of the pelvic columns by inserting screws through the holes of the three flanges. 2 - the main fragment of the damaged acetabulum; 9 - a large skewer; 10 - the first flange; 12 - wits; 13 - the third flange; 14 - polyethylene liner; 15 - bone cement.

In FIG. 17 shows a photo of modeling on the cadaveric material of the acetabular B2.2 fracture according to the international classification AO / ASIF by osteotomy of the acetabulum with diastasis between the fragments. 2 - the main fragment of the damaged acetabulum associated with the ilium; 3 - part of the articular surface of the acetabulum; 4 - the back column of the acetabulum; 5 - line fracture of the posterior column of the acetabulum; 6 - line of transverse fracture of the acetabulum; 7 - the front column of the acetabulum; 8 - line fracture of the anterior column of the acetabulum; 9 - a large skewer.

In FIG. 18 is a photo of the result of a preliminary open reposition of acetabular fragments using tools. 2 - the main fragment of the damaged acetabulum associated with the ilium; 3 - part of the articular surface of the acetabulum; 4 - the back column of the acetabulum; 7 - the front column of the acetabulum; 9 - a large skewer.

In FIG. 19 is a photo of the installation of the reposition - fixation support ring in the acetabulum with the introduction of a screw into the main fragment of the acetabulum through one of the group of holes in the first ring flange. 2 - the main fragment of the damaged acetabulum associated with the ilium; 9 - a large skewer; 10 - the first flange of the ring; 11 - a group of holes in the region of the first and second flanges; 12 - screw; 13 - the third flange of the ring.

In FIG. 20 shows a photo of the insertion of screws into the posterior and anterior columns of the pelvis. 2 - the main fragment of the damaged acetabulum associated with the ilium; 9 - a large skewer; 10 - the first flange of the ring; 12 - wits; 13 - the third flange of the ring.

In FIG. 21 is a photo reposition of the acetabulum using a tool. 12 - vits inserted into the posterior and anterior columns of the pelvis; 13 - a tool for pulling up and reposition of fragments.

In FIG. 22 is a photo of the insertion of screws (12) through all the free holes in the ring.

In FIG. 23 is a photo of additional fixation of the columns of the acetabulum by inserting screws through the holes of the three flanges. 2 - the main fragment of the damaged acetabulum; 9 - a large skewer; 10 - the first flange; 12 - wits; 13 - the third flange; 14 - polyethylene liner; 15 - bone cement.

The method is as follows.

The corpse is laid on its side, we perform the classic external - front access of the Harding type (Fig. 6), used for hip joint replacement (Fig. 7), we perform osteotomy of the femoral neck, remove the femoral head, and remove the trochanteric region posteriorly. Next, we model the acetabular fracture of type B2.2 according to the international classification AO / ASIF by osteotomy of the acetabulum with the creation of diastasis between the columns of the acetabulum (Fig. 8). At the next stage, we perform (Fig. 9) a preliminary reposition by drawing closer the displaced columns of the acetabulum so as to achieve their most accurate comparison (Fig. 9). Then we install in the acetabulum of the corresponding acetabulum the size of the reposition and fixation support ring so (Fig. 10) so that the first flange (10) is above the upper edge of the acetabulum, and the second flange is located at the confluence of the ischium and the posterior edge of the acetabulum, and the third the flange (13) is installed at the confluence of the front edge of the acetabulum and the horizontal branch of the pubic bone. After that, the ring is fixed with screws (Fig. 11) to the articular surface of the main fragment of the acetabulum associated with the ilium by screwing the screws into pre-drilled channels (Fig. 12-12) through a group of holes (Fig. 12-11) of the support ring located within the articular surface of the main fragment of the acetabulum associated with the ilium. Then we sequentially screw one screw at an angle into the rear column through the corresponding hole in the ring (hole in the ring adjacent to the conditional center or middle of the joint surface of the column) and its joint surface, and into the front column through the corresponding hole in the ring (hole in the ring adjacent to the conditional the center or middle of the articular surface of the column) and its articular surface (Fig. 13-12), leaving a part of each screw above the inner surface of the ring (Fig. 13). Next, we continue the repositioning of the acetabulum by alternately pulling the columns with the tool for the protruding parts of the screws screwed into them (Fig. 14) so as to simultaneously create mutual compression between the main fragment of the acetabulum associated with the ilium, the posterior and anterior columns of the acetabulum, on the one hand, and creating mutual compression between the main fragment of the acetabulum, the posterior and anterior columns of the acetabulum and the ring, on the other hand. And, without loosening the thrust for the screws, we rotate the latter one by one into the back and front columns until the screw head stops at the edges of the ring hole. At the same time, the angle we set when introducing screws into the front and back columns of the acetabulum creates, when they are screwed in, with the simultaneous effect of pulling the displaced columns to the ring, the necessary direction of movement of the columns, which contributes not only to the maximum approximation of the columns of the acetabulum both to each other and to the main fragment of the acetabulum associated with the ilium, but also contributes to the maximum adaptation of the articular surface of the columns and the main fragment of the acetabulum associated with the ilium directly to the outer surface of the ring. Adaptation is controlled by the degree of matching of the edges of the acetabulum. The degree of matching of the articular surface of the cavity is monitored through the holes of the ring. And alternately screwing the screws into the columns of the acetabulum to the stop of the screw head in the edge of the hole of the ring contributes to the final reposition of the columns of the acetabulum and simultaneously fixing them to the ring (Fig. 15). We perform a load on the pelvic bones for the possible presence of mobility between the columns, and between the columns and the ring. At the next stage, we screw until the stop (after preliminary drilling of the channels for screws) into the columns of the acetabulum through all the free holes in the ring screws at different angles, and thus strengthen the fixation of the columns to the ring, while the location of the holes in the ring allows you to enter at least three screws into the main mass of the anterior (the junction of the horizontal branch of the pubic bone and acetabulum) and posterior (the junction of the sciatic and acetabulum) columns and securely fix the columns of the acetabulum to the reposition and fixation ring. Then the ring is additionally fixed to the walls of the acetabulum by introducing screws through the holes of the three flanges (Fig. 16).

Experimental example

The corpse is laid on its side, we perform the classic external - front access of the Harding type (Fig. 6), used for hip joint replacement (Fig. 7), we perform osteotomy of the femoral neck, remove the femoral head, and remove the trochanteric region posteriorly. Next, we model the acetabular fracture of type B2.2 according to the international classification AO / ASIF by osteotomy of the acetabulum with the creation of diastasis between the columns of the acetabulum (Fig. 17). At the next stage, we perform (Fig. 17) a preliminary reposition by drawing closer the offset columns of the acetabulum so as to achieve the most accurate comparison (Fig. 18). Then we install in the acetabulum of the corresponding acetabulum the size of the reposition and fixation support ring so that (Fig. 19) so that the first flange (10) is above the upper edge of the acetabulum, and the second flange is located at the confluence of the ischium and posterior edge of the acetabulum, and the third the flange (13) is installed at the confluence of the front edge of the acetabulum and the horizontal branch of the pubic bone. After that, the ring is fixed with screws (Fig. 19) to the articular surface of the main fragment of the acetabulum associated with the ilium by screwing the screws into pre-drilled channels (Fig. 19-12) through a group of holes (Fig. 19-11) of the support ring located within the articular surface of the main fragment of the acetabulum associated with the ilium. Then we sequentially screw one screw at an angle into the rear column through the corresponding hole in the ring (hole in the ring adjacent to the conditional center or middle of the joint surface of the column) and its joint surface, and into the front column through the corresponding hole in the ring (hole in the ring adjacent to the conditional the center or middle of the articular surface of the column) and its articular surface (Fig. 20-12), leaving a part of each screw above the inner surface of the ring (Fig. 21). Next, we continue the repositioning of the acetabulum by alternately pulling the columns with the tool for the protruding parts of the screws screwed into them (Fig. 21) so as to simultaneously create mutual compression between the main fragment of the acetabulum associated with the ilium, the posterior and anterior columns of the acetabulum, on the one hand, and creating mutual compression between the main fragment of the acetabulum, the posterior and anterior columns of the acetabulum and the ring, on the other hand. And, without weakening the thrust for the screws (Fig. 22-12), we rotate the latter one by one into the back and front columns to the stop of the screw head at the edges of the ring hole. At the same time, the angle we set when introducing screws into the front and back columns of the acetabulum creates, when they are screwed in, with the simultaneous effect of pulling the displaced columns to the ring, the necessary direction of movement of the columns, which contributes not only to the maximum approximation of the columns of the acetabulum both to each other and to the main fragment of the acetabulum associated with the ilium, but also contributes to the maximum adaptation of the articular surface of the columns and the main fragment of the acetabulum associated with the ilium directly to the outer surface of the ring. Adaptation is controlled by the degree of matching of the edges of the acetabulum. The degree of matching of the articular surface of the cavity is monitored through the holes of the ring. And alternately screwing the screws into the columns of the acetabulum to the stop of the screw head in the edge of the hole of the ring contributes to the final reposition of the columns of the acetabulum and simultaneously fixing them to the ring (Fig. 22). We perform a load on the pelvic bones for the possible presence of mobility between the columns, and between the columns and the ring. At the next stage, we screw until the stop (after preliminary drilling of the channels for screws) into the columns of the acetabulum through all the free holes in the ring screws at different angles, and thus strengthen the fixation of the columns to the ring, while the location of the holes in the ring allows you to enter at least three screws (Fig. 10, 12) into the main mass of the anterior (the junction of the horizontal branch of the pubic bone and acetabulum) and posterior (the junction of the sciatic and acetabulum) columns and securely fix the columns of the acetabulum to the reposition and fixation ring. Then the ring is additionally fixed to the walls of the acetabulum by introducing screws through the holes of the three flanges (Fig. 23).

Thus, the developed method of open reduction and fixation of displaced acetabular fractures allows you to use:

- classic external - front access of the Harding type to the hip joint and acetabulum, which allows for an overview of the acetabulum, to assess the position of the displaced columns, the degree of damage to the cartilaginous surface of the cavity;

- the use of the classic external-anterior access of the Harding type to the hip joint and acetabulum allows you to:

- reduce the time of surgery, because only one external access to the hip joint is used, therefore, to reduce blood loss;

- minimize the trauma of tissues by optimizing the performance of surgical intervention;

- to maximally exclude the detachment of soft tissues from bone fragments and prevent a violation of the blood supply to the fragments and columns of the acetabulum, which helps to optimize the conditions for reparative osteogenesis;

execute:

- under visual control, the preliminary and final open maximally accurate reposition of the columns of the acetabulum, the maximum adaptation and stable fixation of the columns to the reposition-fixation support ring;

- the predetermined angle when introducing screws into the front and rear columns of the acetabulum creates, when the screws are screwed, while pulling the displaced columns to the ring, the necessary direction of movement of the columns to the main fragment of the acetabulum associated with the ilium, which contributes not only to the maximum approximation of the columns of the acetabulum and the main fragment of the acetabulum associated with the ilium, but also the maximum adaptation of the articular surface of the columns of the acetabulum directly to the outer surface of the ring;

- at the same time, the location of the holes in the ring allows you to insert at least three screws into the bulk of the front and rear columns and securely fix the columns of the acetabulum to the reposition and fixation ring;

- the presence of flanges allows for additional fixation of fragments of columns of the acetabulum to the support ring, which increases the stability of fixation;

- subsequent hip arthroplasty;

- early onset of active restoration of movements in the operated joint objectively has a positive therapeutic effect;

provides:

- early economic effect, consisting in reducing the cost of treatment through the use of only one external - front access to the hip joint, and therefore, reducing the expenditure of surgical material.

- long-term economic effect, consisting in the early rehabilitation of the patient, reducing the time of disability, and therefore, the cost of treatment.

- there is a social effect due to the restoration of the quality of life of the patient.

Claims (1)

The method of open reposition and fixation of displaced acetabular fractures in an experiment, which consists in performing surgical access, exposing fragments of the acetabulum, their open reposition with fixation with screws and plates, characterized in that the corpse is laid on its side, Harding has an external-anterior access to the hip joint used for hip arthroplasty, anterior dislocation of the femur is performed, then an osteotomy of the femoral neck is performed, the femoral head is removed, the trochanteric part of the femur is removed posteriorly, then the acetabular fracture of type B2.2 according to the international classification AO / ASIF is performed by osteotomy of the acetabulum with by creating diastasis between the columns, at the next stage, the offset columns of the acetabulum are brought closer to each other, achieving the most accurate reposition, then the repositionally-fixed support ring is installed in the acetabulum of the size of the acetabulum so that the first flange was located above the upper edge of the acetabulum, and the second flange was placed at the confluence of the ischium and posterior edge of the acetabulum, and the third flange was installed at the confluence of the anterior edge of the acetabulum and the horizontal branch of the pubic bone, then the ring is fixed to the articular surface of the main fragment of the acetabulum ileal cavity by introducing screws through a group of holes of the support ring within the articular surface of the main fragment of the acetabulum, then one screw is inserted in sequence at an angle into the rear column through the corresponding hole in the ring and its articular surface and into the front column through the corresponding hole of the ring and its articular surface, leaving a part of each screw above the inner surface of the ring, then continue repositioning the acetabulum by pulling the columns by the screws and creating mutual compression between the main fragment of the acetabulum adins associated with the ilium, the posterior and anterior columns of the acetabulum, on the one hand, and creating mutual compression between the main fragment of the acetabulum, the posterior and anterior columns of the acetabulum and the ring on the other hand, then, without loosening the thrust for the screws, the latter alternately screw into the rear and front columns until the screw head stops at the edges of the ring hole, after which they carry out a load on the bones, revealing mobility between the columns and between the columns and the ring, at the next stage, screws are inserted into the columns of the acetabulum through all free holes in the ring at different angles enhancing the fixation of the columns to the ring, then the ring is additionally fixed to the walls of the acetabulum by introducing screws through the holes of the three flanges.

Images