RU2779374C1 - Method for correction of posttraumatic deformation of the fib bone 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 deformities of the fibula. Steosynthesis of the bones of the lower leg and foot is performed with an external fixation device 3, for this purpose two supports 8 and 11 are installed with two spokes 9, 10, 12, 13 in each. The supports are connected by threaded rods 7. Then, a fixation-reposition support 14 is installed. A pin with a thrust pad is passed through the neck of the talus 17, two needles are passed through the body of the calcaneus 19 and fixed on a U-shaped support 22. The fixation-reposition and U-shaped supports connected with threaded rods. In the projection of the apex of the deformity, a longitudinal approach is performed, an osteotomy of the fibula is performed in the oblique-sagittal plane, and the subluxation of the foot is eliminated. When the correct position of the talus is reached, the external ankle is repositioned.

EFFECT: method provides correction of fibula deformity by eliminating rotational and axial displacements, displacements in width and length, ensuring stable fixation of the reached position of the fragments and creating favorable conditions for fusion of osteotomy zones due to a set of techniques of the claimed invention.

1 cl, 7 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 fibula under conditions of external fixation in the treatment of improperly consolidated suprasyndesmotic fractures of the fibula.

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 replacement of the defect with an autograft from the iliac crest [3], or from the distal tibial metaepiphysis bones [4] with subsequent fixation of fragments with a bone plate.

According to the literature [5], the corrective fibula osteotomies described above are an effective way to treat patients with improperly consolidated suprasyndesmotic fractures of the lateral malleolus. However, rigid external subluxations of the foot, which are often observed in such injuries, require arthrolysis during simultaneous correction, which consists in releasing the medial angle of the ankle joint, which, together with the extended access necessary for installing the plate, increases the invasiveness of the surgical intervention. Corrective osteotomies of the fibula followed by bone osteosynthesis 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 the absence of fusion, corrective osteotomy is either performed distally to the nonunion zone, followed by osteosynthesis of the fibula with a plate with simultaneous fixation of nonunion and osteotomy zones, which leads to a decrease in fixation stability; or refreshing/resection of the ends of the fragments is performed with the formation of an even larger defect, which increases the invasiveness of the surgical intervention and creates doubtful conditions for stable osteosynthesis and integration of the bone graft (required to replace the defect).

Known methods for simultaneous correction of the length of the outer malleolus by its oblique frontal [6], oblique [patent RU 2216291 C1], or Z-shaped [7, patent RU 2528819] osteotomy osteotomy at the level of the distal tibiofibular syndesmosis and bringing down the distal fragment with subsequent fixation of the fragments with a bone plate . These surgical interventions are effective in the treatment of improperly consolidated trans-syndesmous fractures of the lateral malleolus, however, when the apex of the deformity is located proximal to the distal tibiofibular syndesmosis, one-stage correction occurs with a significant displacement of the fragments in width with the formation of a stepped deformity and a small area of contact between the fragments.

The disadvantages of the known methods are as follows. Osteotomy proximal to the deformity apex in case of an incorrectly consolidated suprasyndesmotic fracture and gradual reduction of the distal fragment leads to tension of the interosseous membrane, which is intact between the osteotomy zone and the deformity apex. Therefore, bringing down is possible only within small limits (up to 0.5 cm), otherwise, it will lead to varus deformity of the fibula. Dissection of the interosseous membrane from the osteotomy zone to the apex of the deformity leads to an increase in the trauma of the surgical intervention and disruption of the blood supply to the distal fragment.

Known methods are applicable in the presence of a consolidated suprasyndesmotic fracture of the outer malleolus, with a small amount of deformation. In the case of an ununited fracture of the fibula or its significant deformity, an osteotomy is required at the apex of the deformity with processing of the ends of the fragments, which adversely affects the blood supply to the fragments and increases the risk of hypotrophic regenerate and nonunion. The possibility of correcting the shortening of the outer malleolus and displacement in width within small limits is provided, if it is impossible to correct rotational and axial displacements, since the hybrid or rod arrangement of the apparatus has insufficient purely degrees of freedom. There is no possibility of gradual reduction of the rigid external subluxation of the foot due to the insufficient degree of fixation rigidity and the absence of fixation elements on the foot. There is no possibility of simultaneous correction of the length of the outer ankle.

Thus, the known methods have disadvantages and require improvement.

The problem to be solved by the invention is the correction of the deformity of the fibula by eliminating its axial displacement, displacements in width and length, ensuring stable fixation of the achieved position of the fragments and creating favorable conditions for the fusion of the osteotomy zone.

The essence of the technical solution

The technical result consists in providing correction of the fibula deformity 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 fibula under conditions of external fixation, minimally invasive correction of the deformity is performed, for this, osteosynthesis of the bones of the lower leg and foot is performed with an external fixation apparatus, a support is installed at the level of the proximal metadiaphysis of the tibia, containing two spokes, a second support is installed at a distance in the range from 2 cm to 3 cm proximal to the apex of the deformity, containing two spokes with thrust pads, the supports are connected by threaded rods, a fixation-reposition support is installed at the level of the distal metaepiphysis of the tibia, on which two spokes with thrust pads are mounted parallel to each other friend in the oblique plane in the direction from back to front at the level of the distal third of the diaphysis of the fibula and the lateral malleolus, through the neck of the talus from the inside to the outside parallel to the axis of the ankle joint, a pin with a thrust platform is passed through the body two wires are inserted into the calf bone and fixed on a U-shaped support with tension, the fixation-reposition and U-shaped supports are connected with threaded rods, longitudinal access is performed in the projection of the vertex of the deformity, osteotomy of the fibula is performed in the oblique-sagittal plane, subluxation of the foot is eliminated by positioning the fixation- repositioning and U-shaped supports by manual traction or by moving the hinges and threaded rods of the external fixation apparatus; when the correct position of the talus is reached, the lateral malleolus is repositioned by positioning the fixation-reposition support relative to the U-shaped support with the remaining shortening of the lateral malleolus.

The method is a minimally invasive surgical intervention with known advantages of minimally invasive technique.

A minimally invasive correction of the fibula deformity is achieved by its osteotomy distal to the apex of its osteosynthesis deformity under conditions of external fixation (Ilizarov apparatus), which provides controlled stable fixation of fragments for immediate or gradual correction of the deformity and early function of the operated limb.

The claimed method is a minimally invasive surgical intervention, since it requires a longitudinal access without the need for a wide dissection of tissues, which only ensures reaching the bone with an osteotome, or with an oscillating saw blade.

EFFECT: method enables correction of fibula deformities accompanied by significant shortening of the fibula and axis deviation due to oblique osteotomy distal to the deformity apex with elimination of axial displacement, as well as displacement in width and length.

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 fixation period, which allows early loading on the operated limb and rehabilitation measures.

The method allows both simultaneous and gradual elimination of deformity and reduction of foot subluxation by means of 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.

The method allows to create both relative stability due to compression at the junction of the fragments due to their shape and by 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 osteotomy and/or non-union.

The method can be carried out with nonunion and false joint of the fibula.

The method allows 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 explained by graphic materials

Fig. 1. Scheme of the lower leg in two projections. Post-traumatic deformity of the diaphysis of the fibula, outward subluxation of the foot, scheme in two projections.

Fig. 2. Scheme of the lower leg in two projections. Osteosynthesis of the bones of the lower leg and foot with the Ilizarov apparatus, corrective oblique osteotomy of the fibula.

Fig. 3. Scheme of the lower leg, showing the stages of correction in the Ilizarov apparatus: on the left - distraction of the lateral malleolus and reduction of the external subluxation of the foot; on the right, elimination of arthrodiastasis and restoration of the length of the lateral malleolus.

Fig. 4. Scheme of the lower leg in two projections. Lower leg and foot after deformity correction.

Fig. 5. Scheme. From top to bottom, the levels and positions of the transosseous elements are shown: 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 third of the diaphysis of the fibula; at the level of the distal tibiofibular syndesmosis.

Fig. 6. Scheme of transosseous elements on the foot and at the level of the distal tibiofibular syndesmosis;

Fig. 7. Scheme of indirect reposition of the external subluxation of the foot behind the talus.

Specification:

1 - fibula;

2 - tibia;

3 - external fixation device;

4 - the top of the deformation;

5 - zone of osteotomy;

6 - chisel;

7 - threaded rods;

8 - 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 - spoke with thrust pad;

16 - a spoke with a thrust pad;

17 - talus;

18 - spoke with thrust pad;

19 - calcaneus;

20 - knitting needle;

21 - knitting needle;

22 - U-shaped support;

23 - hinge.

Implementation of the invention

A method for correcting post-traumatic fibula deformity under conditions of external fixation is used to correct post-traumatic fibula deformity in the treatment of improperly consolidated suprasyndesmotic fibula fractures.

In the method, osteosynthesis of the bones of the lower leg and foot is performed with an external fixation apparatus (the Ilizarov apparatus is used).

A support 8 is installed at the level of the proximal metadiaphysis of the tibia 2, containing at least two spokes 9 and 10. One spoke 9 is passed through the tibia 2, the other spoke 10 with a thrust pad is carried out in the direction from the outside to the inside through the head of the fibula 1 and the tibia bone 2 (Fig. 5)

A second support 11 is installed, at a distance in the range of 2 to 3 cm proximal to the top of the deformation, containing at least two spokes 12 and 13 with thrust pads, one 12 of which is drawn in an oblique frontal plane in the direction from the inside out. Support 11 can be additionally reinforced with a rod-screw (not shown) inserted into the diaphysis of the fibula 1 (Fig. 5). Base supports 8 and 11 are connected by threaded rods 7 with nuts.

A fixation-reposition support 14 is installed, annular or semicircular, at the level of the distal metaepiphysis of the tibia 2, on which two pins 15 and 16 with thrust pads are directly and with the help of brackets, drawn parallel to each other in the oblique sagittal plane in the direction from back to front at the level of the distal thirds of the diaphysis of the fibula and the outer malleolus (Fig. 5).

Through the neck of the talus 17 from the inside out parallel to the axis of the ankle joint, a spoke 18 with a thrust platform is passed. Two spokes 20 and 21 are passed through the body of the calcaneus 19. The spokes 20 and 21 are fixed on the U-shaped support 22 with tension (Fig. 6)

To increase the rigidity of fixation, it is possible to pass an additional two wires through the diaphysis of the I-II and V-III metatarsal bones, followed by their fixation on the support and brackets.

Fixation-reposition 14 and U-shaped supports 22 are connected by threaded rods 7 with nuts.

In the projection of the top of the deformation 4 perform a longitudinal access. Produce osteotomy 5 of the fibula 1 in the oblique plane (Fig. 2). Next, the subluxation of the foot is eliminated by positioning the fixation-reposition 14 and U-shaped 22 supports relative to the proximal supports 8 and 11, by manual traction or by moving the action of the hinges 23 and the nodes of the external fixation apparatus 3, the Ilizarov apparatus (Fig. 3) to achieve the correct position of the talus block 17, the external ankle is repositioned by positioning the fixation-reposition support 14 relative to the U-shaped support 22 with the remaining shortening of the external ankle. In the case of residual tibiofibular diastasis, the diastasis is eliminated by positioning the pins 15 and 16, passed through the outer ankle and the distal third of the diaphysis of the fibula, or by holding and tensioning in the fixation-reposition support 14 of the pin with a thrust platform, drawn 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). Restoration of relationships in the ankle joint is achieved, the wound is sutured in layers.

In case of rigid deformities and an unsuccessful attempt to simultaneously reduce the subluxation, the wound is sutured in layers, and the fragments of the fibula 1 are returned to their original position.

Produce, gradually and dosed, deformity correction in sequence.

Arthrodistraction of the ankle joint is performed by distraction between the fixation-repositioning 14 and the base supports 11 and 8. Atrodistraction is performed to avoid conflict of the articular surfaces during the subsequent correction of the deformity.

Perform the correction of the angular deformity of the fibula 1 by creating a varus stress with the help of hinges 23 of the external fixation apparatus 3, single-plane or two-plane. When mounting single-plane hinges 23 outward from the inner cortical layer of the tibia 2 (above the inner angle of the ankle joint) at the level of osteotomy 5, the valgus deformity is corrected simultaneously with the reduction of the subluxation.

The subluxation of the foot is reduced by moving the fixation-reposition 14 and U-shaped 22 supports inward by tensioning the needle 12 with a thrust platform drawn in the oblique frontal plane in the direction from the inside out in the base support 11 (Fig. 6), or by positioning the supports 14 and 22 with support beams and threaded rods in case of extremely rigid deformation.

The outer ankle is brought down by compression between the fixation-reposition 14 and U-shaped supports using threaded rods 7 and nuts.

Claimed method:

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

2) Allows correction of fibula deformities accompanied by its significant shortening and axis deviation due to oblique osteotomy distal to the deformity apex with elimination of axial displacement, as well as displacement in width and length;

3) Provides stability of fragments and manageability 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;

4) Allows you to perform 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 fixing the foot;

5) Allows you to create both relative stability due to compression at the junction of the fragments due to their shape 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 inter-fragmentary compression at the level of osteotomy and/or nonunion;

6) Due to the previous paragraphs, the method is feasible for nonunion and false joint of the fibula;

7) 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.

The technical result is a minimally invasive technique for correcting the deformity of the fibula by osteotomy distal to the top of the deformity of its osteosynthesis under the conditions of the Ilizarov apparatus, which provides controlled stable fixation of fragments for one-stage or gradual correction of the deformity and early function of the operated limb.

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 Sat-isfaction and Function. Case Reports in Orthopedics. 2015. 1-5. 10.1155/2015/549109.

7. Thangarajah, Tanujan & Lakdawala, Ayaz & Battaloglu, Emir & Malik, Atul & Tillu, Ab-hay. (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.

Claims (1)

A method for correcting post-traumatic deformity of the fibula under external fixation, characterized in that a minimally invasive correction of the deformity is performed, for this, osteosynthesis of the bones of the leg and foot is performed with an external fixation device, a support is installed at the level of the proximal metadiaphysis of the tibia, containing two spokes, the support is installed at a distance of range from 2 cm to 3 cm proximal to the apex of the deformity, containing two spokes with thrust pads, the supports are connected by threaded rods, a fixation-reposition support is installed at the level of the distal metaepiphysis of the tibia, on which two spokes with thrust pads are mounted parallel to each other in the oblique sagittal plane in the direction from back to front at the level of the distal third of the diaphysis of the fibula and the outer malleolus, through the neck of the talus from the inside to the outside parallel to the axis of the ankle joint, a pin with a thrust platform is passed through the body of the calcaneus yat two spokes and fixed on a U-shaped support with tension, the fixation-reposition and U-shaped supports are connected with threaded rods, longitudinal access is performed in the projection of the vertex of the deformity, osteotomy of the fibula is performed in the oblique-sagittal plane, subluxation of the foot is eliminated by positioning the fixation-reposition and U-shaped supports by manual traction or by the movement of hinges and threaded rods of the external fixation device; when the correct position of the talus is reached, the lateral malleolus is repositioned by positioning the fixation-reposition support relative to the U-shaped support with the remaining shortening of the lateral malleolus.

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