RU2779373C1 - Method for correction of posttraumatic deformation of the external ankle under external fixation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics, and can be used to correct post-traumatic deformity of the lateral malleolus under conditions of external fixation. Minimally invasive correction of the deformity of the lateral malleolus is performed by double osteotomy of the fibula and bilocal osteosynthesis. To do this, the bones are fixed with an external fixation device and an osteotomy of the fibula is performed at the top of the deformity. Then the reposition of the external subluxation of the foot is performed. Next, an oblique osteotomy is performed at the level of the middle third of the diaphysis of the fibula, the shortening is compensated, and the defect is replaced by distraction osteosynthesis, bringing down the fragment of the fibula.

EFFECT: method provides correction of external malleolus deformity due to elimination of rotational and axial displacements, displacements in width and length, provides stable fixation of the achieved position of the fragments and creation of favorable conditions for fusion of osteotomy zones due to a set of techniques of the claimed invention.

1 cl, 9 dwg

Description

Technical field

The technical solution relates to medicine, in particular, to traumatology, and can be used to correct post-traumatic deformity of the lateral malleolus under conditions of external fixation in the treatment of improperly consolidated transsyndesmotic fractures of the lateral malleolus.

State of the art

There are known methods of simultaneous lengthening of the fibula by its Z-shaped osteotomy at the level of the distal third of the diaphysis [1], as well as transverse osteotomy without the use of a bone graft [2] and with the replacement of the defect with an autograft from the iliac crest [3], or from the distal metaepiphysis of the tibia bones [4] with subsequent fixation of fragments with a bone plate.

According to the literature [5], the above-described corrective osteotomies of the fibula are an effective way to treat patients with improperly consolidated suprasyndesmotic fractures of the lateral malleolus, characterized by a violation of the integrity of the tibiofibular ligaments and the interosseous membrane distal to the fracture level. In case of transsyndesmotic fractures of the lateral malleolus, without violating the integrity of the posterior tibiofibular ligament and interosseous membrane (at least proximal to the level of the distal tibiofibular joint), one-stage correction of the length of the lateral malleolus due to supramalleolar osteotomy is possible to a limited extent, while ensuring tension of the interosseous ligaments, which in in some cases it is a favorable circumstance, due to their excessive lengthening. Otherwise, this action leads to an increase in the morbidity of the surgical intervention. In addition, the often observed angular deformity and displacement of the outer malleolus along the width, combined with its shortening, are not eliminated by osteotomy of the distal third of the fibula shaft, since the apex of the deformity is localized in the area of transsyndesmosis fracture.

Known methods of simultaneous correction of the length of the outer malleolus by its oblique frontal [6], oblique [patent RU 2216291 C1], or Z-shaped [7] osteotomy at the apex of the deformity and reduction of the distal fragment, followed by fixation of the fragments with a bone plate.

These surgical interventions are effective in the treatment of improperly consolidated transsyndesmotic fractures of the lateral malleolus, however, they require an access that allows the installation of a plate and screws, leading to devascularization of the fracture zone, osteotomy, which adversely affects the regenerative potential of fragments and surrounding soft tissues. In addition, these methods are carried out in conditions of osteoporosis of the parafracture bone tissue and are possible only upon reaching the consolidation of the fracture and are not applicable to the early stages of the post-fracture process. In the absence of union, surgical intervention is complicated by even more pronounced osteoporosis and the need to refresh the ends of the fragments with the formation of an extensive defect, which creates doubtful conditions for stable osteosynthesis and integration of the bone graft required to replace the defect.

There are known methods for correcting the length of the outer malleolus due to its osteotomy and gradual lengthening with the formation of a distraction regenerate under conditions of external fixation [8, 9].

Like the methods described above, they are applicable to consolidated fractures with satisfactory bone quality. Otherwise, they are accompanied by the risk of the formation of a hypotrophic regenerate and nonunion. In addition, these surgical interventions require an increase in the duration of external fixation due to the correction period.

A known method for the treatment of chronic improperly fused fractures of the external malleolus (patent RU 2528819 C1), which consists in performing corrective osteotomy at the top of the deformity and simultaneous correction of the deformity, followed by osteosynthesis of the bones of the lower leg and foot with an external fixation device. This method is characterized by a minimally invasive surgical intervention, favorable conditions for the fusion of fragments, controllability of the position of the fragments throughout the entire period of fixation, and the possibility of early loading on the operated limb.

However, the implementation of the method is possible only in the presence of a consolidated cross-syndesmous fracture of the lateral malleolus and a small amount of deformation. Otherwise, osteotomy of the nonunion zone should be accompanied by processing of the ends of fragments with the formation of a significant defect, which, in conditions of severe osteoporosis and bone deficiency, creates unfavorable conditions for fusion and reduces the stability of osteosynthesis. An oblique, or Z-shaped osteotomy is performed according to the second rule of osteotomy, which leads to a displacement of the fragments in width, or to the formation of a stepped deformity. There is no possibility of gradual reduction of the rigid external subluxation of the foot due to the insufficient degree of fixation rigidity.

Thus, the known methods have disadvantages and require improvement.

The problem to be solved by the invention is to correct the deformity of the outer malleolus by eliminating rotational and axial displacements, displacements in width and length, ensuring stable fixation of the achieved position of the fragments and creating favorable conditions for the fusion of osteotomy zones.

The essence of the technical solution

The technical result consists in providing correction of the deformity of the outer malleolus by eliminating rotational and axial displacements, displacements in width and length, ensuring stable fixation of the achieved position of the fragments and creating favorable conditions for the fusion of osteotomy zones.

The technical result is achieved by the fact that in the method for correcting post-traumatic deformity of the lateral malleolus under conditions of external fixation, minimally invasive correction of the deformity of the lateral malleolus is performed by double osteotomy of the fibula and bilocal osteosynthesis, for this the bones are fixed with an external fixation device, while setting the proximal base ring support at the level of the proximal metadiaphysis of the tibia, containing two spokes, one spoke is passed through the tibia, the second spoke with a thrust pad is passed in the direction from the outside to the inside through the head of the fibula and the tibia, then an annular support is installed at the level of the border of the middle and distal thirds of the diaphysis of the tibia, containing one a pin with a thrust pad, drawn in the oblique frontal plane in the direction from the inside outward parallel to the axis of the ankle joint, an annular fixation-reposition support is installed at the level of the distal metaepiphysis of the tibia the fibula, then an osteotomy of the fibula is performed at the apex of the deformity, a double-edged wire is inserted into the distal fragment, the wire is brought out with its distal end through the area of the apex of the outer malleolus above the skin, the proximal end of the wire reaches the zone of osteotomy, then the wire is retrogradely advanced into the medullary canal of the fibula, through the neck of the talus from the inside outward parallel to the axis of the ankle joint, a spoke with a thrust platform is passed, two spokes are passed through the body of the calcaneus and fixed on a U-shaped support, a spoke with a thrust platform is passed through the outer ankle from the back to the front and fixed to the U-shaped support, through the distal third of the diaphysis of the fibula is passed from front to back with a pin with a thrust platform and attached to a fixation-reposition support, then an oblique osteotomy is performed at the level of the middle third of the diaphysis of the fibula, the shortening is compensated and the defect is replaced by distraction osteosynthesis, bringing the fragment of the fibula into f fixation-reposition support with displacement in width anteriorly without loss of contact between the fragments, external subluxation of the foot is eliminated by tension of the pin passed through the distal metaepiphysis of the tibia in the oblique-frontal plane in the direction from the inside outward parallel to the axis of the ankle joint and fixed on the fixation-reposition support or by positioning the U-shaped support of the external fixation device, while repositioning the external subluxation is performed by displacing the tibia outward and displacing the talus inward, the wounds are sutured in layers.

The method is a minimally invasive surgical intervention, with the known advantages of a minimally invasive technique, since only two longitudinal accesses are performed, ensuring that the bone is reached by an osteotome, or an oscillating saw blade, without the need for wide tissue dissection.

EFFECT: method provides elimination of external ankle deformity, accompanied by its significant shortening and deviation of the longitudinal axis due to bilocal osteosynthesis of the fibula, performing osteotomy at the top of the deformity with the elimination of axial and rotational displacements, as well as displacements in width, and oblique osteotomy at the level of the middle third of the fibula shaft to compensate for shortening and replacement of a defect;

The method is applicable for non-union and false joint of the outer malleolus, since the defect formed after processing the ends of the fragments is replaced by a reduced proximal fragment by bilocal osteosynthesis with adequate contact at the junction of the fragments;

The method ensures the stability of the fragments and controllability of the position of the fragments, as well as the possibility of modular transformation and gradual dismantling of the fixation elements throughout the entire period of fixation, which allows for early loading on the operated limb and rehabilitation measures.

EFFECT: method allows to perform both simultaneous and gradual elimination of deformity and reduction of foot subluxation by means of both direct and indirect reposition due to positioning of the pins passed through the outer ankle in the oblique sagittal plane and the diaphysis/metadiaphysis of the tibia in the plane of the ankle joint axis, as well as by positioning foot support.

The method makes it possible to create both relative stability due to the intracanal spoke, which prevents the fragments from shifting in width and shunting the load between the proximal base support and the support that fixes the foot; and absolute stability due to the possibility of axial, counter-lateral and combined interfragmentary compression at the level of both osteotomies.

The method provides for the installation of additional fixation elements to eliminate associated deformities, allowing the installation of an individual layout of the external fixation apparatus, depending on the clinical situation.

The technical solution is illustrated by graphic materials.

Fig. 1. Post-traumatic deformity of the lateral malleolus, outward subluxation of the foot, view of the limb bones in two projections.

Fig. Fig. 2. Corrective osteotomy of the lateral malleolus, view of the bones of the limb in two projections, a chisel is shown.

Fig. Fig. 3. Osteosynthesis of the bones of the lower leg and foot with an external fixation device, corrective osteotomy of the diaphysis of the fibula, a view of the bones of the limb in two projections, a chisel and the Ilizarov apparatus are shown.

Fig. Fig. 4. Deformity correction in the Ilizarov apparatus, bilocal compression of the osteotomy zones, view of the limb bones in two projections.

Fig. Fig. 5. Lower leg and foot after deformity correction, view of the limb bones in two projections.

Fig. 6. The levels and positions of the transosseous elements (pins) are sequentially shown, from top to bottom: at the level of the condyles of the tibia; at the level of the middle third of the leg; at the level of the distal tibiofibular syndesmosis; at foot level.

Fig. 7. Reposition of the external subluxation by moving the tibia outward.

Fig. 8. Indirect reposition of the external subluxation by displacing the talus medially.

Fig. 9. Radiographs. A double-edged pin is inserted into the fibula, up to the osteotomy zone.

Specification:

1 - fibula;

2 - tibia;

3 - external fixation device;

4 - zone of osteotomy;

5 - zone of osteotomy;

6 - chisel;

7 - bone fragment;

8 - base support;

9 - knitting needle;

10 - a spoke with a thrust pad;

11 - support;

12 - spoke with thrust pad;

13 - knitting needle;

14 - fixation-reposition support;

15 - knitting needle;

16 - bone fragment;

17 - double-edged knitting needle;

18 - spoke with thrust pad;

19 - knitting needle;

20 - U-shaped support;

21 - spoke with thrust pad;

22 - bone fragment.

Implementation of the invention

A method for correcting post-traumatic deformity of the lateral malleolus under conditions of external fixation is used in the treatment of improperly consolidated transsyndesmotic fractures of the lateral malleolus. The method is based on minimally invasive correction of a multicomponent deformity of the lateral malleolus by double osteotomy of the fibula 1 and its bilocal osteosynthesis under conditions of external fixation with the Ilizarov apparatus, which provides controlled stable fixation of fragments and early function of the operated limb.

In the method, the bones are fixed with an external fixation device 3. Bilocal osteosynthesis of the fibula 1 is performed. To do this, osteotomy 4 of the fibula 1 is performed at the top of the deformity, axial and rotational displacement, and displacements in width are eliminated. The reposition of the external subluxation is performed by moving the tibia outward. Indirect reposition of the external subluxation is performed by displacing the talus medially. An oblique osteotomy 5 is performed at the level of the middle third of the diaphysis of the fibula 1, shortening and replacement of the defect are compensated by distraction osteosynthesis, bringing down the fragment 22 of the fibula 1.

Before performing osteotomy and correction, external fixation of the leg bones is performed with an external fixation apparatus 3, for example, with the Ilizarov apparatus.

A proximal base annular support 8 is installed at the level of the proximal metadiaphysis of the tibia 2, containing at least two spokes 9,10. One spoke 9 is passed through the tibia 2, the second spoke with a thrust pad 10 is passed in the outside-in direction through the head of the fibula 1 and the tibia 2 (Fig. 6).

An annular support 11 is installed at the level of the border of the middle and distal thirds of the diaphysis of the tibia, containing at least one spoke with a thrust platform 12, carried out in an oblique frontal plane in the direction from the inside outward parallel to the axis of the ankle joint (intermalleolar line in the axial plane). The support 11 can be reinforced by passing the pin 13 through the diaphysis of the tibia 2 and the fibula 1, or by a rod-screw (not shown) introduced into the diaphysis of the fibula 1 (Fig. 6).

An annular fixation-reposition support 14 is installed at the level of the distal metaepiphysis of the tibia 2, designed to fix the pins 15. The pin 14 does not contain pins 15 at the initial stage, the pins 15 are mounted during the surgical repositioning technique.

Longitudinal external access is performed in the projection of the apex of the deformation of the external ankle. Chisel 6 perform osteotomy 4 at the top of the deformity (Fig. 2). The ends of the bone fragments 7,16 are processed with a rasp and a bone rasp in order to create a larger contact area at the junction of the fragments 7,16. Next, a double-edged wire 17 is inserted into the distal fragment 16, the wire 17 is brought out with its distal end through the zone of the top of the outer ankle above the skin, the proximal end of the wire 17 reaches the osteotomy zone. Next, the needle 17 (Fig. 9), retrogradely carried out in the medullary canal of the fibula 1. The wound is sutured in layers.

Through the neck of the talus from the inside out, parallel to the axis of the ankle joint, a spoke 18 with a thrust platform is passed. Through the body of the calcaneus are two spokes 19. The spokes 19 are fixed on the U-shaped support 20 with tension (Fig. 6). To increase the rigidity of fixation, it is possible to pass an additional two wires through the diaphyses of the I-II and V-III metatarsal bones. Next, the subluxation of the foot is eliminated by traction with the hands, or with the help of an external fixation device 3, using the hinges and nodes of the external fixation device 3. Upon reaching the reduction of the subluxation and the correct position of the foot distal to the osteotomy zone 4 in the sagittal plane, a needle 21 s is passed through the outer ankle from behind to the front. stubborn platform. The spoke 21 is fixed on the brackets to the U-shaped support 20. If the distal fragment 16 of the outer ankle is incorrectly positioned, the spoke 21 passed through it is attached to the U-shaped support 20 on threaded rods and brackets, taking into account the offset and is lowered by shortening the threaded rods.

Proximal to the zone of osteotomy 4 in the sagittal plane through the distal third of the diaphysis of the fibula 1 front-to-back spend the needle 15 with a thrust platform. The needle 15 is attached with tension on the brackets to the fixation-reposition support 14 to enable positioning of the outer ankle along the length.

Perform a longitudinal external access to the diaphysis of the fibula 1 at the level of the middle/distal third in the area of the maximum diameter of the medullary canal. Taking into account the shortening, an oblique osteotomy 5 of the fibula 1 (Fig. 3) is performed according to the second rule of osteotomies: to correct the length of the outer malleolus, the distal fragment 22 of the fibula 1 is lowered in the fixation-reposition support 14 with a shift in width (anteriorly) without loss of contact between the fragments 7.16. (Fig. 4). The wound is sutured in layers.

With persistent external subluxation of the foot, the latter is eliminated by tensioning the needle 12, passed through the distal metaepiphysis of the tibia 2 in the oblique frontal plane in the direction from the inside outward parallel to the axis of the ankle joint (intermalleolar line in the axial plane) and fixed on the fixation-reposition support 14 (Fig. .7).

An alternative option for reducing the subluxation is the simultaneous or gradual positioning of the U-shaped support 20 (Fig. 8).

Claimed method:

- is a minimally invasive surgical intervention, as it requires two longitudinal approaches without the need for a wide tissue dissection, which only ensures reaching the bone with an osteotome, or with an oscillating saw blade;

- allows correction of deformities of the lateral malleolus, accompanied by its significant shortening and deviation of the axis due to bilocal osteosynthesis of the fibula: osteotomy at the apex of the deformity with the elimination of axial and rotational displacements, as well as displacements in width, and oblique osteotomy at the level of the middle third of the diaphysis of the fibula to compensate shortening and replacement of the defect;

- due to the previous paragraph, it is possible with non-union and false joint of the external ankle, since the defect formed after processing the ends of the fragments is replaced by a reduced proximal fragment by bilocal osteosynthesis, ensuring adequate contact at the junction of the fragments;

- ensures the stability of the fragments and controllability of the position of the fragments, as well as the possibility of modular transformation and gradual dismantling of the fixation elements throughout the entire fixation period, which allows early loading on the operated limb and rehabilitation measures;

- allows both simultaneous and gradual elimination of deformity and reduction of subluxation of the foot through both direct and indirect reposition due to the positioning of the pins passed through the outer ankle in the oblique sagittal plane and the diaphysis / metadiaphysis of the tibia in the plane of the ankle joint axis, as well as positioning of the support that fixes the foot.

- allows you to create both relative stability due to the intracanal needle, which prevents the fragments from shifting in width and shunting the load between the proximal base support and the support that fixes the foot; and absolute stability due to the possibility of axial, counter-lateral and combined interfragmentary compression at the level of both osteotomies.

- allows the installation of additional fixation elements to eliminate associated deformities, allowing the installation of an individual layout of the external fixation device, depending on the clinical situation.

Cited sources. Non-Patent Literature

1. Weber, D & Friederich, Niklaus & Müller, W. (1998). Lengthening osteotomy of the fibula for post-traumatic malunion. Indications, technique and results. International orthopaedics. 22.149-52. 10.1007/s002640050229.

2. Chao, Kuo-Hua & Wu, Chia-Chun & Lee, Chian-Her & Chu, Cheng-Mien & Wu, Shing-Shen. (2004). Corrective-Elongation Osteotomy Without Bone Graft for Old Ankle Fracture With Residual Diastasis. Foot & ankle international / American Orthopedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 25.123-7. 10.1177/107110070402500302.

3. Sinha, Apurv & Sirikonda, Siva & Giotakis, Nikolaos & Walker, Christopher. (2008). Fibular Lengthening for Malunited Ankle Fractures. Foot & ankle international / American Orthopedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 29. 1136-40. 10.3113/FAI.2008.1136.

4. El Rosasy, Mahmoud & Aly, Tarek. (2013). Realignment-lengthening osteotomy for malunited distal fibular fracture. International orthopaedics. 37. 10.1007/s00264-013-1876-7.

5. van Wensen RJ, van den Bekerom MP, Marti RK, van Heerwaarden RJ. Reconstructive osteotomy of fibular malunion: review of the literature. Strategies Trauma Limb Reconstr. 2011 Aug;6(2):51-7. doi: 10.1007/s11751-011-0107-2. Epub 2011 Apr 6. PMID: 21818702; PMCID: PMC3150649.

6. Inori, Fumiaki & Tohyama, Masahiko & Yasuda, Hiroyuki & Konishi, Sadahiko & Waseda, Akeo. (2015). Reconstructive Osteotomy for Ankle Malunion Improves Patient Satisfaction and Function. Case Reports in Orthopedics. 2015. 1-5. 10.1155/2015/549109.

7. Thangarajah, Tanujan & Lakdawala, Ayaz & Battaloglu, Emir & Malik, Atul & Tillu, Abhay. (2012). Lengthening z-Osteotomy of the Fibula to Correct Persistent Talar Shift Following Open Reduction Internal Fixation of Ankle Fractures. Foot & ankle specialist. 5. 107-10. 10.1177/1938640011434509.

8. Rozbruch SR, DiPaola M, Blyakher A. Fibula lengthening using a modified Ilizarov method. Orthopedics. 2002 Nov;25(11):1241-4. PMID: 12452340.

9. Johnston, A.J., Andrews, C.T. Fibular lengthening by Ilizarov method secondary to shortening by osteochondroma of distal tibia. Strat Traum Limb Recon 3, 45–48 (2008). https://doi.org/10.1007/s11751-007-0028-2

10. Prissel MA, Daigre JL, Brandão RA, Philbin TM, Hyer CF, Berlet GC. Cross-Sectional Analysis of the Distal Fibular Intramedullary Canal: A Cadaveric Evaluation. Foot Ankle Spec. 2018 Jan 1:1938640017751190. doi: 10.1177/1938640017751190. Epub ahead of print. PMID: 29361841.

Claims (1)

A method for correcting post-traumatic deformity of the lateral malleolus under conditions of external fixation, characterized in that minimally invasive correction of the deformity of the lateral malleolus is performed by means of a double osteotomy of the fibula and bilocal osteosynthesis; for this, the bones are fixed with an external fixation device, while installing a proximal base ring support at the level of the proximal metadiaphysis of the tibia bone containing two wires: one wire is passed through the tibia, the second wire with a thrust pad is passed in the direction from the outside to the inside through the head of the fibula and the tibia, then an annular support is installed at the level of the border of the middle and distal thirds of the diaphysis of the lower leg, containing one spoke with a thrust with a platform drawn in the oblique frontal plane in the direction from the inside outward parallel to the axis of the ankle joint, an annular fixation-reposition support is installed at the level of the distal metaepiphysis of the tibia, then an osteotomy of the fibula is performed at the apex of the deformity, a double-edged wire is inserted into the distal fragment, the wire is brought out with its distal end through the zone of the apex of the outer malleolus above the skin, the proximal end of the wire reaches the osteotomy zone, then the wire is retrogradely passed into the medullary canal of the fibula, through the neck of the talus from the inside outward, parallel to the axis of the ankle joint, a pin with a thrust pad is passed, two pins are passed through the body of the calcaneus and fixed on a U-shaped support, a pin with a thrust pad is passed through the outer ankle from back to front and fixed to the U-shaped support, through the distal third of the diaphysis of the fibula bones are passed from front to back with a pin with a thrust platform and attached to a fixation-reposition support, then an oblique osteotomy is performed at the level of the middle third of the diaphysis of the fibula, the shortening is compensated and the defect is replaced by distraction osteosynthesis, bringing the fragment of the fibula into the fixation-reposition this support with an anterior displacement in width without loss of contact between the fragments, the external subluxation of the foot is eliminated by tensioning the pin passed through the distal metaepiphysis of the tibia in the oblique frontal plane in the direction from the inside outward parallel to the axis of the ankle joint and fixed on the fixation-reposition support, or by positioning U-shaped support of the external fixation device, while the reposition of the external subluxation is performed by displacing the tibia outward and displacing the talus inward, the wounds are sutured in layers.

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