RU2758477C1 - Method for treating false joints of the navicular bone of the hand - Google Patents

Abstract

FIELD: surgery.

SUBSTANCE: invention relates to medicine, namely to hand surgery, and can be used for treating non-united fractures and false joints of the navicular bone of the hand. A shortened arc-shaped palmar or dorsal access is performed. Antegrade or retrograde osteosynthesis of fragments of the navicular bone of the hand is then performed. A channel is then formed using a cannulated drill, whereto a cannulated compression Herbert screw is screwed along a pin. Then a channel is formed under control of an electron-optical converter (EOC) to the right and to the left from the cannulated compression Herbert screw perpendicular to the fracture line. A spongy autograft is taken in the area of the distal radial metaepiphysis, and spongy columns are inserted into the formed channels under the control of the EOC, then the cannulated compression Herbert screw is tightened.

EFFECT: method provides a minimal degree of tissue trauma, a reduction in the time of union of fractures of the navicular bone and reduction of the period of temporary incapacity for work of patients due to the application of shortened surgical accesses, miniarthrotomy, elimination of additional manipulations with fragments in the cavity of the joint, method for taking and inserting a bone autograft, as well as compression of the bone graft during fragment fixation.

1 cl, 4 dwg, 4 ex

Description

The invention relates to medicine, in particular to hand surgery, and can be used to treat false joints of the scaphoid bone of the hand.

Analogs

In the treatment of pseudarthrosis of the scaphoid, there are various types of surgical interventions aimed at achieving reduction, stable fixation of bone fragments and stimulation of osteogenesis.

Various types of bone grafting are used to stimulate osteogenesis.

According to the method of Russe O. (1960), access to the area of the pseudarthrosis is carried out from the palmar side directly outward from the radial flexor of the hand. In the fragments, a groove is formed in the longitudinal direction of the bone (0.6 × 0.6 × 1.5 cm), while simultaneously removing the sclerosed endplates. A somewhat large graft is taken from the iliac crest and, after appropriate processing, is placed in the prepared bed, the remaining cancellous shavings are packed into the lumens.

According to the method of L. Barnard and S. Stubbins (1948), the resected styloid process of the radius is used as an autograft. At the same time, in the fragments of the scaphoid bone in the longitudinal direction, the authors form a canal, into which a resected styloid process is introduced, which has been pretreated in the shape of the canal.

Some authors suggest resection of the styloid process of the radius with styloidectomy.

Kuzmenko V.V., Korshunov V.F., Magdiev D.A. (1998) used distraction devices for treatment, after passing the Kirschner wires through the proximal metaphysis of the II-V metacarpals and the forearm bones, a distraction device is mounted in the lower third, and from the second day, dosed distraction begins at a rate of 1 mm / day until the wrist joint is stretched by 5- 6 mm. Then the rate of distraction is reduced to 0.5 mm / day and stretching is continued by 7-8 mm.

Criticism of analogues

The use of pins and screws for a pseudarthrosis, along with the need for a second operation to remove them, is associated with the risk of developing both intraoperative and postoperative complications. These include: fragmentation of fragments at the slightest technical errors of osteosynthesis, the development of the phenomena of metallosis. inflammation and resorption of the bone at its border with the metal, which reduces the already limited amount of scaphoid substance and the chances of fusion of the pseudarthrosis.

Styloidectomy, along with its palliativeness, is inevitably accompanied by dysfunction of the wrist joint and weakening of the hand function, and the use of the resected styloid process of the radius as a graft is associated with the need to create a sufficiently large bone bed corresponding to it in bone fragments of the scaphoid bone. The ratio of the sizes of scaphoid fragments and autografts is such that a significant part of the bone substance is scooped out of the former, which, firstly, makes them hollow, thin-walled and fragile, and secondly, disrupts the already meager blood supply. This increases the risk of nonunion of the pseudarthrosis and requires more time to rebuild the autograft.

The same disadvantages are inherent in the use of a massive (in relation to a relatively small navicular bone) cylindrical graft taken from the metaphysis of the radius or iliac crest. In addition, the risk of complications from donor sites is not excluded and osteosynthesis of bone fragments with Kirschner wires or screws is necessary.

The use of distraction devices for external fixation as devices for repositioning bone fragments of the scaphoid is far from always effective, and their use only as a preliminary treatment (for more convenient surgical access to bone fragments) is impractical.

Prototype

As a prototype, we chose the method of autoplasty of bone fragments of the scaphoid according to A.I. Ashkenazi. Method A.I. Ashkenazi (1990) is that through the dorsal or dorsal-radial access, the position of the scaphoid fragments is corrected. A cylindrical hollow cutter with an outer diameter of 7-8 mm is used to form a cylindrical defect between the bone fragments in the dorsal-palmar direction. In this case, the front wall of the fragment is left intact. A cylindrical graft taken from the iliac crest with cutters with an outer diameter of 8-9 mm is inserted into the cavity. Temporary stabilization of the wrist joint is performed with needles and a plaster cast is applied.

Criticism of the prototype

Along with the advantages, namely the reposition of bone fragments and autoplasty of the pseudarthrosis of the scaphoid with a cortical-cancellous graft, the prototype method also has significant disadvantages. These include the following:

- traumatic dorsal-ray access, skeletonization of bone fragments

- drilling of repositioned bone fragments with a drill with a diameter of 7-8 mm is accompanied by a decrease in the already limited amount of their bone substance and the area of contact between them, which reduces their meager blood supply and increases the time of engraftment and restructuring of the autograft;

- due to the expenditure of more time for the restructuring of the autograft and, accordingly, the need to increase the terms of immobilization of the wrist joint, the likelihood of persistent contracture in it and functional disorders of the patient's hand increases;

- unstable osteosynthesis with wires

- the need for postoperative long-term immobilization with a plaster cast, limiting the movement of the fingers and access to the surgical wound during dressings, the risk of developing contracture of the wrist joint.

Purpose of invention

The aim of the invention is to improve the efficiency of treatment of patients with pseudarthrosis of the scaphoid bone, the use of minimally invasive techniques, to reduce the operation time. This goal is achieved by performing a palmar retrograde approach or a dorsal antegrade approach, depending on the location of the fracture, to perform bone autoplasty, then osteosynthesis and stable fixation of the damaged bone fragments.

The essence of the invention

The essence of the proposed method is illustrated in Fig. 1, fig. 2, where

Pos. 1 - spoke

Pos. 2 - channel formed by a 3 mm drill

Pos. 3 - Herbert screw

The essence of the proposed method is as follows: at the fracture line in the middle and distal third of the bone, surgical access to the bone is performed from the palmar side of the wrist to perform retrograde osteosynthesis of fragments, the introduction of a cannulated compression screw through the area of the navicular tubercle towards the wrist joint. The upper limb is given a position of extension in the wrist at an angle of 20-30 °, a shortened arcuate palmar access is performed from the level of the base of the I metacarpal bone towards the tendon of the radial flexor of the hand and further along its projection up to 2 cm long to perform retrograde osteosynthesis of fragments, introduction of a cannulated compression screw through the area of the navicular tubercle towards the wrist joint.

The tubercle of the scaphoid is exposed, after which, with the help of a guide pin, the pin is passed through the fragments of the scaphoid from the distal-radial surface of the tubercle to the proximal pole of the bone (Fig. 1). The angle of inclination for the guide wire is 45 ° towards the dorsum of the wrist and 45 ° towards the projection of the ulna. Under the control of an electro-optical converter (EOC), the correctness of the guide wire passing through the scaphoid fragments is assessed. Further, using a cannulated drill and a tap, a canal is formed. The length of the screw is determined in advance by comparative radiographs, as well as using the capabilities of X-ray computed tomography, a computer program for visualizing wrist pathology and other measuring devices. Based on the measurement results, then a cannulated compression screw is screwed into the channel formed in the bone fragments along the needle, without tightening it by 0.2-0.03 mm (Fig. 1). Under the control of the image intensifier, a guide wire is introduced on the sides of the screw, perpendicular to the line and along them with a cannulated drill d = 3 mm, a canal is formed (Fig. 1). Next, a spongy autograft is taken in the region of the distal metaphysis of the radius using a minimally invasive method using a cannulated needle for trepanation biopsy (Fig. 1). The guide wire is removed and, under the control of the image intensifier, spongy columns are introduced into the pre-formed canals. Then screw to the end, providing compression to the fragments and spongy autograft. The positioning of the screw in the fragments of the scaphoid bone is also monitored radiographically. The operation ends with layer-by-layer wound sutures.

2 The essence of the proposed method is as follows: at the fracture line in the middle and proximal third of the bone, surgical access to the bone is carried out from the back of the wrist to perform antegrade osteosynthesis of fragments, the introduction of a cannulated compression screw through the zone of the proximal third of the scaphoid towards the base of the metacarpal bone of the hand ... The upper limb is given a position of flexion at the wrist at an angle of 30-40 °, a shortened arcuate dorsal approach is performed from the level of c \ 3 of the wrist joint in the projection of the fold towards the base of 1 metacarpal bone and further along its projection up to 2 cm long to perform antegrade osteosynthesis fragments, the introduction of a cannulated compression screw through the area of the proximal third of the scaphoid in the direction to the bases of 1 metacarpal bone.

The proximal end of the scaphoid is exposed, after which, using a guide pin, the pin is passed through the fragments of the scaphoid from the proximal pole of the scaphoid to the distal pole of the bone (Fig. 1). The angle of inclination for the guide wire is 45 ° towards the palmar surface of the wrist and 45 ° towards the projection of the bases of 1 metacarpal bone. Under the control of an electron-optical converter (EOC), the correctness of the wire passing through the fragments of the scaphoid is assessed. Further, using a cannulated drill and a tap, a canal is formed. The length of the screw is determined in advance by comparative radiographs, as well as using the capabilities of X-ray computed tomography, a computer program for visualizing wrist pathology and other measuring devices. Based on the measurement results, then a cannulated compression screw is screwed into the channel formed in the bone fragments along the needle, without tightening it by 0.2-0.03 mm (Fig. 2, pos. 3). Under the control of the image intensifier, a guide wire is inserted on the sides of the screw, perpendicular to the line and along them with a cannulated drill d = 3 mm, a canal is formed. Next, a spongy autograft is taken in the region of the distal metaphysis of the radius using a minimally invasive method using a cannulated needle for trepanation biopsy. The guide wire is removed and, under the control of the image intensifier, spongy columns are introduced into the pre-formed canals. Further, the Herbert screw (pos. 3) is tightened to the end, providing compression to the fragments and spongy autograft. The positioning of the screw in the fragments of the scaphoid bone is also monitored radiographically. The operation ends with layer-by-layer wound sutures.

Examples of specific implementation of the method

Example 1

Patient A., 26 years old, was admitted to the trauma department of the RCTO in a planned manner with a diagnosis: False joint of the scaphoid bone of the left wrist joint. From the anamnesis: trauma 1.5 years ago, was treated on an outpatient basis, at the place of residence. On admission on radiographs and CT: a picture of the pseudarthrosis of the scaphoid bone of the left wrist joint.

After preoperative preparation, under conduction anesthesia, an operation was performed using minimally invasive technology according to our proposed method. A shortened arcuate palmar approach was performed from the level of the base of the I metacarpal bone towards the tendon of the radial flexor of the hand and further along its projection up to 2 cm long. tubercle to the proximal pole of the bone. Under the control of an electro-optical converter (EOC), the correctness of the wire passing through the fragments of the scaphoid was assessed. Then, using a cannulated drill and a tap, a canal was formed. Based on the measurement results, a cannulated compression screw was then inserted into the canal formed in the bone fragments along the needle, without tightening it by 0.2-0.3 mm. Under the control of the image intensifier, guide wires were inserted on the sides of the screw, perpendicular to the fracture line and along them with a cannulated drill d = 3 mm, a canal was formed. Next, a spongy autograft was taken in the region of the distal metaphysis of the radius using a minimally invasive method using a cannulated needle for trepanation biopsy.

Under the control of the image intensifier, spongy columns were introduced into the pre-formed channels. Further, the Herbert screw was screwed in to the end, thereby providing compression with a fragment and a spongy autograft

The positioning of the screw in the scaphoid fragments was also monitored radiographically. The operation was completed with layer-by-layer wound sutures. A smooth postoperative course was observed in dynamics. Complete fusion was noted after 3.5 months. After 6 months: no complaints, works at his previous job (taxi driver). Full range of motion in the wrist joint, painless

Example 2

Patient M., 45 years old, was admitted to the trauma department of the RCTO in a planned manner with a diagnosis of False joint of the scaphoid bone of the right wrist joint. From the anamnesis: trauma 20 years ago, was treated on an outpatient basis, at the place of residence. On admission on radiographs and CT: a picture of the pseudarthrosis of the scaphoid of the right wrist joint

After preoperative preparation, under conduction anesthesia, an operation was performed using minimally invasive technology according to our proposed method. A shortened arcuate palmar approach was performed from the level of the base of the I metacarpal bone towards the tendon of the radial flexor of the hand and further along its projection up to 2 cm long. tubercle to the proximal pole of the bone.

Under the control of an electro-optical converter (EOC), the correctness of the wire passing through the fragments of the scaphoid was assessed. Then, using a cannulated drill and a tap, a canal was formed. Based on the measurement results, a cannulated compression screw was then inserted into the canal formed in the bone fragments along the needle, without tightening it by 0.2-0.3 mm. Under the control of the image intensifier, guide wires were inserted on the sides of the screw, perpendicular to the fracture line and along them with a cannulated drill d = 3 mm, a canal was formed. Next, a spongy autograft was taken in the region of the distal metaphysis of the radius using a minimally invasive method using a cannulated needle for trepanation biopsy.

Under the control of the image intensifier, spongy columns were introduced into the pre-formed channels. Further, the Herbert screw was screwed in to the end, thereby providing compression with a fragment and a spongy autograft

The positioning of the screw in the scaphoid fragments was also monitored radiographically. The operation was completed with layer-by-layer wound sutures. A smooth postoperative course was observed in dynamics. Complete fusion was noted after 3.5 months. After 6 months: no complaints, works at his previous job (taxi driver). Full range of motion in the wrist joint, painless

A smooth postoperative course was observed in dynamics. Complete fusion was noted and appeared after 5 months, no complaints. Actively involved in sports Movement in the wrist joint in full, painless

Example 3

Patient Sh., 19 years old, was admitted to the trauma department of the RCTO in a planned manner with the diagnosis: False joint of the scaphoid bone of the right wrist joint. From the anamnesis: trauma 2 years ago, did not go to doctors, for consultations after examination, surgical treatment was recommended in a planned manner. On admission on radiographs and CT: a picture of the pseudarthrosis of the scaphoid of the right wrist joint.

After preoperative preparation, under conduction anesthesia, an operation was performed using minimally invasive technology according to our proposed method. A shortened arcuate dorsal approach is performed from the level c \ 3 of the wrist joint in the projection of the fold towards the base of 1 metacarpal bone and further along its projection up to 2 cm long to perform antegrade osteosynthesis of fragments, introduction of a cannulated compression screw through the zone of the proximal third of the scaphoid in the direction to the bases of 1 metacarpal bone.

The proximal end of the scaphoid is exposed, after which, using a guide pin, the pin is passed through the fragments of the scaphoid from the proximal pole of the scaphoid to the distal pole of the bone (Fig. 1). The angle of inclination for the guide wire is 45 ° towards the palmar surface of the wrist and 45 ° towards the projection of the bases of 1 metacarpal bone. Under the control of an electron-optical converter (EOC), the correctness of the wire passing through the fragments of the scaphoid is assessed. Further, using a cannulated drill and a tap, a canal is formed. The length of the screw is determined in advance by comparative radiographs, as well as using the capabilities of X-ray computed tomography, a computer program for visualizing wrist pathology and other measuring devices. Based on the measurement results, then a cannulated compression screw is screwed into the channel formed in the bone fragments along the needle, without tightening it by 0.2-0.3 mm. Under the control of the image intensifier, a guide wire is introduced on the sides of the screw, perpendicular to the line and along them with a cannulated drill d = 3 mm, a canal is formed. Next, a spongy autograft is taken in the region of the distal metaphysis of the radius using a minimally invasive method using a cannulated needle for trepanation biopsy. The guide wire is removed and, under the control of the image intensifier, spongy columns are introduced into the pre-formed canals. Further, the Herbert screw (pos. 3) is tightened to the end, providing compression to the fragments and spongy autograft. The positioning of the screw in the fragments of the scaphoid bone is also monitored radiographically. The operation ends with layer-by-layer wound sutures.

A smooth postoperative course was observed in dynamics. Complete fusion was noted, appeared after 7 months, no complaints. Actively involved in sports Movement in the wrist joint in full, painless

Example 4

Patient A, 55 years old, was admitted to the trauma department of the RCTO in a planned manner with the diagnosis: False joint of the scaphoid bone of the right wrist joint. From the anamnesis: trauma 8 years ago, 5 years ago in the City Hospital, surgical treatment was performed - Osteosynthesis of the right wrist joint in an external fixation apparatus according to G.A. Ilizarov. in distraction mode for 3 months. The fracture did not grow together with complaints of pain in the right wrist joint, aggravated by physical exertion, limitation of movement in the wrist joint, he turned to consultations, after examination, surgical treatment was recommended as planned .. On admission on radiographs and CT: a picture of the pseudarthrosis of the scaphoid bone of the right wrist joint ...

After preoperative preparation, under conduction anesthesia, an operation was performed using minimally invasive technology according to our proposed method. A shortened arcuate dorsal approach is performed from the level c \ 3 of the wrist joint in the projection of the fold towards the base of 1 metacarpal bone and further along its projection up to 2 cm long to perform antegrade osteosynthesis of fragments, introduction of a cannulated compression screw through the zone of the proximal third of the scaphoid in the direction to the bases of 1 metacarpal bone.

The proximal end of the scaphoid is exposed, after which, using a guide pin, the pin is passed through the fragments of the scaphoid from the proximal pole of the scaphoid to the distal pole of the bone. The angle of inclination for the guide wire is 45 ° towards the palmar surface of the wrist and 45 ° towards the projection of the bases of 1 metacarpal bone. Under the control of an electron-optical converter (EOC), the correctness of the wire passing through the fragments of the scaphoid is assessed. Further, using a cannulated drill and a tap, a canal is formed. The length of the screw is determined in advance by comparative radiographs, as well as using the capabilities of X-ray computed tomography, a computer program for visualizing wrist pathology and other measuring devices. Based on the measurement results, then a cannulated compression screw is screwed into the channel formed in the bone fragments along the needle, without tightening it by 0.2-0.3 mm. Under the control of the image intensifier, a guide wire is introduced on the sides of the screw, perpendicular to the line and along them with a cannulated drill d = 3 mm, a canal is formed. Next, a spongy autograft is taken in the region of the distal metaphysis of the radius using a minimally invasive method using a cannulated needle for trepanation biopsy. The guide wire is removed and, under the control of the image intensifier, spongy columns are introduced into the pre-formed canals. Further, the Herbert screw is tightened to the end, providing compression to the fragments and spongy autograft. The positioning of the screw in the fragments of the scaphoid bone is also monitored radiographically. The operation ends with layer-by-layer wound sutures. A smooth postoperative course was observed in dynamics. Complete fusion was noted, appeared after 8 months, no complaints. Movement in the wrist joint in full, painless.

Features of the invention that differ from the prototype

- surgical access to the navicular bone is carried out from the palmar side of the wrist 2 cm,

- retrograde osteosynthesis of fragments is performed by the introduction of a cannulated Herbert compression screw through the area of the navicular tubercle towards the wrist joint,

° к плоскости проведенного винта Герберта, по которым канюлированным сверлом d=2 мм, формируют канал,- under the control of an electro-optical converter (EOC), a guide wire is inserted along the line of the pseudarthrosis on the left and right and at an angle of 90

° to the plane of the drawn Herbert screw, along which a channel is formed with a cannulated drill d = 2 mm,

- then a spongy autograft is taken in the region of the distal metaepiphysis of the radial bone, the wire is removed,

- under the control of the image intensifier, spongy columns are introduced into the pre-formed channels,

- then the Herbert screw is tightened.

The positive effect of the application of the invention

The proposed method for the treatment of the pseudarthrosis of the navicular bone of the hand is a minimally invasive surgical technology that provides a differentiated approach (palmar retrograde or dorsal antegrade osteosynthesis) to stable fixation of damaged bone fragments. The minimum degree of tissue trauma due to the use of shortened surgical approaches, miniarthrotomy, exclusion of additional manipulations with fragments in the joint cavity, the method of taking and inserting an autograft bone, as well as compression of a bone graft when fixing fragments. All this contributes to a reduction in the time of healing of fractures of the scaphoid bone and a decrease in the period of temporary disability of patients. The results of the implementation of the method are shown in FIG. 3 and FIG. 4

Sources of information

1. Ashkenazi A.I. Wrist joint surgery. M .: Medicine, 1990.S. 351 p. - prototype.

2. Kuzmenko V.V., Korshunov V.F., Magdiev D.A. Treatment of nonunited fractures and pseudarthrosis of the scaphoid by distraction. Bulletin of Traumatology and Orthopedics named after I. N.N. Priorova, 1998. - N 2. - S. 11-14.

3. Barnard L., Stubbins S.Q. Stuloidectomy of the Radius in Surgical Treatment of nonunion of carpal scaphoid. J. Bone Joint Surg., 1948. - Vol. 30. - P. 98-102.

4. Russe O. Fracrure of the cerpal naviculare // J. Bone Joint Surg. 1960. - V 01.42 A. - N 5. - P. 759-768.

Claims (3)

A method of treating the pseudoarthrosis of the navicular bone of the hand, which consists in correcting the position of fragments of the scaphoid, characterized in that at the fracture line in the middle and distal third of the bone, surgical access to the bone is carried out from the palmar side of the wrist, while a shortened arcuate palmar access is performed from the base level 1 metacarpal bone towards the tendon of the radial flexor of the hand and further along its projection up to 2 cm long, then retrograde osteosynthesis is performed using a wire, which is carried out through fragments of the scaphoid from the distal radial surface of the tubercle to the proximal pole of the bone with an angle of inclination for the guide wire 45 ° towards the dorsum of the wrist and 45 ° towards the projection of the ulna; at the fracture line in the middle and proximal third of the bone, surgical access to the bone is carried out from the back of the wrist, while a shortened arcuate dorsal approach is performed from the level of the middle third of the wrist joint in the fold projection towards the base of the metacarpal bone and further along its projection up to 2 cm, then antegrade osteosynthesis is performed with a wire, which is carried out from the proximal pole of the scaphoid to the distal pole of the bone with an angle of inclination for the guide wire of 45 ° towards the palmar surface of the wrist and 45 ° to the projection of the bases of the metacarpal bone; after osteosynthesis of scaphoid bone fragments using a cannulated drill and a tap, a canal is formed into which a cannulated Herbert compression screw is screwed along the needle, then, under the control of an electron-optical converter (EOP), guide wires are inserted to the right and left of the cannulated Herbert compression screw, perpendicular to the fracture line a canal is formed along them with a cannulated drill with a diameter of 3 mm, then a spongy autograft is taken in the region of the distal metaepiphysis of the radial bone, the wire is removed, and under the control of an image intensifier, spongy columns are inserted into the formed canals, then the cannulated Herbert compression screw is tightened.

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