RU2755694C1 - Method for reconstruction of fractures of the lower wall of the orbit at an early age - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology. The operating area is prepared. A sinus catheter prepared in size is installed in the maxillary sinus. The balloon of the sinus catheter is filled with a radiopaque substance. The presence of the balloon in the maxillary sinus is confirmed by computed tomography data. The mobilization and movement of soft tissues with the eyeball to the physiological position is performed. The defect of the lower wall of the orbit is replaced with an alloplant made of highly purified xenocollagen type 1. The sinus catheter is left in the maxillary sinus until the bone fragments and the edges of the fracture of the lower orbital wall are adapted.

EFFECT: method makes it possible to shorten the period of postoperative rehabilitation, improve the orthopedic and functional effect of surgical treatment of fractures of the lower orbital wall in children.

1 cl, 10 dwg, 3 ex

Description

The proposed invention relates to medicine, namely to ophthalmology, and can be used in ophthalmology to restore the lower wall of the orbit in childhood, and is intended for use in operating units of medical and diagnostic institutions.

Modern surgical treatment of fractures of the middle zone of the facial skeleton provides for accurate reconstruction, stable fixation and, if possible, restoration of all damaged structures. At the same time, close attention is paid to the reconstruction of the lower wall of the orbit. Underestimation of this important component of the operation can lead to persistent oculomotor disorders, eno- and hypophthalmos. Various methods are used to reconstruct the lower wall of the orbit in ophthalmology in maxillofacial surgery. They all have their own advantages and disadvantages.

In recent years, there has been an increase in the number of pediatric patients with traumatic injuries of the lower orbital wall, requiring surgical intervention. In case of orbital contusion, isolated fractures of the lower wall are most common, accounting for 35-40%.

Considering the physiological growth of the facial skeleton in childhood, the choice of surgical treatment tactics and plastic material for the restoration of the orbital walls is one of the important tasks of orbital surgery. With the advent of new modern biocomposite materials, endoscopic techniques, orbital surgery has reached a new level.

Elimination of defects and reduction of bone fragments of the lower wall of the orbit ensures the restoration of its anatomical integrity, which is a paramount, aesthetic and functional task.

The known methods of endoprosthetics of the walls of the orbit using synthetic, canned, cartilaginous, fascial, metal endoprostheses have a number of disadvantages, such as: they cause irritation of the surrounding tissues, their secondary displacement occurs, significant resorption occurs in the postoperative period, there is a discrepancy in the bone structure (Dentistry. 1996, N 5. P. 35-42 Combined use of ceramic implants based on hydroxylapatite and fixing devices made of titanium in reconstructive operations in the craniofacial region. GV Meshkov).

The optimal and most effective modern surgical tactics in the treatment of fractures of the craniofacial region is precision microinvasive reduction followed by rigid fixation. The successful outcome of the operation is important from both a functional and aesthetic point of view. This is of particular importance in the treatment of traumatic orbital injuries, where accurate volumetric and anatomical reconstruction is required in order to restore normal functions of the organ of vision, on the one hand, and prevent the development of such late complications as eno- and hypophthalmus, on the other.

The main tasks of the reconstruction of the orbit are the release of the restrained soft tissues of the orbit in the fracture zone, reduction to the physiological position of the eyeball in order to recreate the anatomical integrity of the orbit and reconstruction of its physiological volume

The lower wall of the orbit is not flat and even and has a number of anatomical curves that must be taken into account when choosing an implantation material for its reconstruction. It rises 30 ° in the anteroposterior direction and at an angle of 45 ° in the latero-medial direction. Concavity immediately follows the orbital edge, and in the posterior regions, on the contrary, an upward bend. This protrusion in the posterior regions is of particular importance in the reconstruction of the lower wall, since volume replacement in this zone prevents the development of late postoperative hypo- and enophthalmos.

The main criteria that should be met by an ideal material for plastics of the lower wall of the orbit are: a) sufficient strength to keep the orbital tissues in their normal anatomical position under the influence of gravitational forces; b) biocompatibility; c) plasticity and lightness.

Known surgical methods for eliminating enophthalmos and hypophthalmos, based on the use of auto- and allogeneic skin-cartilage grafts, high molecular weight polymeric materials, titanium metal structures, which are used for plastic surgery of the lower wall of the orbit (Belchenko V.A. and deformations of the facial skeleton using autotransplants of membranous origin and metal structures made of titanium.Autoref.dis.Doctor of medical sciences. - M., 1996; Davydov D.V., Reshetov I.V., Kopylova N.E. and others The use of hydrogel implants in reconstructive surgery of the orbit // Ophthalmosurgery. - 2002. - No. 4. - P. 26-31; Davis RM Late orbital implant migration // Ann. Ophthalmol. - 1986. - Vol. 18. - No. 6. - P. 223-224). However, each of these materials has a number of drawbacks that limit their use: additional trauma when taking an autograft; immunogenicity and, as a consequence, rapid resorption of the graft or its rejection; scarring of surrounding tissues; displacement of the implant. In addition, these methods do not provide for the modeling of the graft to eliminate the cosmetic defect in the form of hypo- and enophthalmos.

As a result of the conducted patent search, the following information was selected.

There is a known method of reconstruction of the walls of the orbit with a fracture, including the reposition of the eyeball, the reduction of the periorbital fat, the reposition of the fragments of the orbit by means of a graft with fixation of the latter, characterized in that two vertical cuts of the mucous membrane of the transitional fold are made below and lateral to the inferior orbital foramen, then holes are formed according to these cuts in the anterior wall of the maxillary sinus, cicatricial adhesions of soft tissues in the area of repaired bone fragments are dissected with the release of periobital fat until it moves freely together with the oculomotor muscle into the cavity of the orbit, a fatty layer is formed between the oculomotor muscle and the bone wall, while the graft is fixed on one side to the anterior part of the lower wall of the orbit, and on the other hand to the bony part of the retrobulbar part of the orbit, bone fragments of the wall of the orbit are sutured with a graft along the entire length (RF patent No. 2286110).

However, in the known method, access to the reconstruction site is carried out through the oral mucosa and the maxillary sinus, which can lead to various inflammatory complications, such as maxillary sinusitis, infection of the orbital tissue with the oral microflora during osteosynthesis. The use of autologous bone can lead to its resorption and the formation of secondary enophthalmos. The patient's consent is required for the collection of the bone graft, which is an additional operation and not all patients agree. The graft must be modeled according to the shape of the defect, which lengthens the operation time.

For the prototype of the proposed technical solution, a method of forming the lower wall of the orbit was chosen, including the reposition and fixation of the orbital bones, mobilization and movement of soft tissues with the eyeball to a normal position, replacement of the defect in the lower wall of the orbit with a graft. The defect is replaced by a muscle temporofascial flap, moved into the orbital cavity through a "window" pre-formed in the outer wall of the orbit, and the flap is laid with the fascial surface towards the maxillary cavity and fixed to the surrounding soft tissues (RF No. 2125430).

The objective of the proposed technical solution is the reconstruction of fractures of the lower wall of the orbit in childhood without limiting the size of the injury, reducing the risk of postoperative complications.

The technical result consists in reducing the time of postoperative rehabilitation, improving the orthopedic and functional effects of surgical treatment of fractures of the lower wall of the orbit in children.

The technical result is obtained by using the method of reconstruction of fractures of the lower wall of the orbit in childhood, including the preparation of the operating area, reposition of the lower wall of the orbit, mobilization and movement of soft tissues with the eyeball to a normal position, replacement of the defect in the lower wall of the orbit with an alloplant made of highly purified xeno-collagen type 1 ... After preparation of the operating area, a prepared sinus catheter is installed in the maxillary sinus, followed by filling its balloon with a radiopaque substance and placing it in the maxillary sinus until complete adaptation of bone fragments and fracture edges of the lower orbital wall, confirmed by computed tomography data.

The authors did not find in the analyzed literature this set of distinctive features that lead to the solution of the problem posed by them.

The authors did not find in the analyzed literature this set of distinctive features that lead to the solution of the problem posed by them.

The proposed technical solution meets the criteria of the invention: "novelty", "inventive step", "industrial applicability".

The sinus catheter consists of a reverse valve, a balloon, and a reinforced latex casing with a channel, designed to inflate the balloon (Figure 10).

The outer opening of the channel is equipped with a syringe adapter. Inside the body there is a plastic rod designed to model the body in accordance with the anatomy of the nasal cavity.

Using a sinus catheter, the doctor, by filling the balloon with a contrast agent through the valve, creates a controlled pressure in the balloon cavity.

From the publicly available information, the use of a sinus catheter in pediatric eye surgery as a device for pressing a tissue flap to a wound surface has not been revealed.

In addition, a feature of the known sinus catheter is that the balloon is made of a latex thin-walled material with elasticity, softness, complete trauma safety and suitability for long-term contact with the skin, nasal mucosa and maxillary sinus of a child. These features allow the use of a sinus catheter as a means of pressing bone fragments of the lower wall of the orbit from the side of the maxillary sinus (Fig. 1 and 2). The sinus catheter in the deflated state of the balloon is placed in the nasal passage corresponding to the fracture zone, after the expansion of the natural anastomosis, the balloon was installed in the maxillary sinus, and then pressure is created in the balloon by injecting a contrast agent, from which the balloon begins to increase in size, in particular, in the transverse ... The filling volume depended on the age of the child. This allows you to press the bone fragments and reposition the fracture to an orthopedic position. Since the latex thin-walled shell of the balloon is easily deformed, crumpled, that is, it changes its shape in places of external resistance, then when the marginal portions of the maxillary sinus mucosa are reached, the balloon is inflated along the end portions and thus most, presses the bone fragments along the entire relief of the fracture zone. The thinness of the shell, the softness of the material and its elasticity provide a tight moth-eye fit along the perimeter of the maxillary sinus. In addition, the balloon, as a fixator for the immobility of the flaps, does not move and does not change its established position, since it is fixed along the edges in the middle nasal passage with tampons. Therefore, the possible mobility of the outside tube is not transferred to the balloon.

The authors propose the use of a single-use latex sinus catheter as a balloon for controlled hydroreposition of bone fragments during contour plasty of the inferior wall of the orbit in children.

The proposed method of plastics was applied in 6 sick children. The age of the patients ranged from 5 to 18 years, with an average of 7.5 years.

The study included 63 patients who were treated at the Morozov Children's City Clinical Hospital from December 2019 to January 2021 with traumatic injuries of the lower wall of the orbit.

To develop tactics for the treatment of patients with traumatic injury to the lower orbital wall, the transverse size of the through defect was taken into account more than 1.0 cm, the value, displacement of fragments of the lower prolapse into the maxillary sinus.

The operation was carried out in 3 stages:

1st stage - transconjunctival access to the lower wall of the orbit, localization of the fracture, evacuation of prolapsed soft tissues of the orbit.

2nd stage - transnasal access. Under the control of 2.7 mm 0 and 30 'Storz rigid endoscopes, the natural anastomosis of the maxillary sinus was expanded in the middle nasal passage, the sinus was sanitized, the fracture was localized, the endoscopic control of evacuation from the fracture zone of the soft tissues of the orbit and, if necessary, instrumental reposition of the prolapsed bone fragment was performed.

Next, a sinus catheter balloon is placed in the sinus lumen, the middle turbinate is lateralized and fixed with a tampon.

Then, under visual control over the movement of bone fragments from the orbital side, their final reduction and fixation in a given position was carried out by filling the balloon with a non-ionic radiopaque solution of iodopromide diluted with saline solution 1:10.

3rd stage - correction of the remaining minimal deformity (or defect) with a membrane of highly purified xenocollagen type 1, tamponade of the middle nasal passage. Monitoring of the position of the inferior wall of the orbit and alloplant was carried out endoscopically, both transnasally and transorbital. The use of a sinus catheter promotes optimal restoration of the integrity of the inferior wall of the orbit and complete evacuation of hernial contents from the fracture zone, thereby improving the orthopedic and functional effects of surgical treatment of fractures of the inferior orbital wall in children. Moreover, the use of a contrasting radiopaque substance for filling the balloon of a sinus catheter allows for a delayed on-line monitoring of the position of the sinus catheter, bone structures of the orbit and the position of the orbital alloplant, which was used as a high-grade xeno-collagen type 1, with dynamic CT. research.

The method is illustrated by the following clinical examples.

Figure 1 (CT of the orbits before surgery, frontal view).

Figure 2 (sinus catheter inserted into the maxillary sinus, frontal view).

Figure 3 (sinus catheter inserted into the maxillary sinus, sagittal view).

Figure 4 (CT of the orbits before surgery, frontal view).

Figure 5 (CT of the orbits after surgery, frontal projection).

Figure 6 (CT of the orbits after surgery, Sagittal view).

Figure 7 (CT of the orbits before surgery, frontal view).

Figure 8 (CT of the orbits after surgery, frontal projection).

Figure 9 (3D reconstruction, CT of the orbits after catheter placement and filling with radiopaque contrast agent).

Figure 10 (Sinus catheter inserted into the maxillary sinus).

Example 1

Patient B., 12 years old, diagnosed with OD - fracture of the lower wall of the orbit complicated with displacement

According to CT of the orbits, the child has a comminuted fracture of the lower wall of the right orbit with a displacement of the bone fragment into the cavity of the orbit and the cavity of the right maxillary sinus, with prolapse of intraorbital tissue up to 8 mm, for up to 10 mm. The rectus muscle pulled up to the fracture area. Intraorbital tissue is involved. The right eyeball has clear, even contours and a homogeneous structure. In the cavity of the right maxillary sinus, pathological contents are determined (see Fig. 1).

The child underwent surgical treatment according to the proposed method.

In the postoperative period, computed tomography was performed on the Toshiba Aquilion Prime apparatus with reconstruction in the multi-spiral scanning mode with a slice thickness of 0.6 mm and a pitch (distance between slices) of -0.25 mm. To assess the condition of the orbital walls, sections were obtained in frontal, axial and sagittal projections and 3D reconstruction.

On the images of computed tomography in frontal and sagittal projections, a sinus catheter balloon filled with a contrast agent is visualized, the upper edge of which presses the lower wall of the orbit, no displacement of fractures is observed (Fig. 2 and Fig. 3).

Example 2

Patient B., 17 years old with a diagnosis of OS - fracture of the lower wall of the orbit complicated with displacement

According to CT of the orbits, the child has a multifragmented fracture of the lower wall of the orbit with the formation of a bone defect up to 23 mm in length and sagging of intraorbital structures into the cavity of the maxillary sinus up to 6-7 mm. The lower rectus muscle of the left eye is thickened, shifted to the fracture zone, its contour is indistinct in places. The orbital tissue of the left eye is compacted. CT scan signs of a left-sided hemosinus of small volume. There is a slight thickening of the mucous membrane of the right upper sinus and the cells of the ethmoid labyrinth (Fig. 4).

The child underwent surgical treatment according to the proposed method. In the postoperative period, a CT scan was performed.

CT scans show a sinus-catheter balloon filled with a contrast agent, the upper edge of which presses the lower wall of the orbit, no displacement of fractures is observed (Figs. 5 and 6).

Example 3

Patient B., 17 years old, diagnosed with OD - fracture of the lower wall of the orbit complicated with displacement

According to CT of the orbits, the child has a fracture of the lower wall of the orbit with the formation of a bone defect up to 2 mm in length and sagging of intraorbital structures into the cavity of the maxillary sinus up to 3 mm. The lower rectus muscle and the lower oblique muscle of the right eye are thickened, pronouncedly displaced into the fracture zone, its contour is indistinct in places. The orbital tissue of the left eye is compacted. CT scan signs of a left-sided hemosinus of small volume. There is a slight thickening of the mucous membrane of the right maxillary sinus and the cells of the ethmoid labyrinth (Fig. 7).

The child underwent surgical treatment according to the proposed method.

Postoperative CT scan was performed

CT scans show a sinus catheter balloon filled with a contrast agent, the upper edge of which presses the lower wall of the orbit, no displacement of fragments is observed (Figs. 8 and 9).

The invention was developed as a result of long-term scientific research related to the search for and the possibility of using a sinus catheter in the surgery of fractures of the lower wall of the orbit with a combined approach, allowing to move away from the use of extended invasive maxillofacial approaches, reducing the likelihood of postoperative complications.

The authors were the first to develop a technique for installing a sinus catheter for the purpose of hydroreposition of bone fragments of the inferior wall of the orbit in children.

The method is completely ready for use in ophthalmic surgery when performing surgical correction of fractures of the lower wall of the orbit in children.

The claimed method is successfully applied in the State Budgetary Healthcare Institution "Morozovskaya Children's City Clinical Hospital" of the DZ of Moscow.

The method has an important clinical, socio-economic significance in terms of reducing the risk of postoperative complications and reducing the time of postoperative rehabilitation.

Claims (1)

A method for reconstruction of fractures of the lower wall of the orbit in childhood, including the preparation of the operating area, reposition of the lower wall of the orbit, mobilization and movement of soft tissues with the eyeball to the physiological position, replacement of the defect in the lower wall of the orbit with an alloplant made of highly purified xeno-collagen type 1, characterized in that after the preparation of the operating zone, a sinus catheter prepared in size is installed in the maxillary sinus, with further filling of its balloon with a radiopaque substance and keeping it in the maxillary sinus until the bone fragments and fracture edges of the lower orbital wall are adapted, confirmed by computed tomography data.

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