RU2782784C1 - Method for calcaneal-tibial arthrodesis in charcot's neuroosteoarthropathy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology, and can be used for performing heel-tibial arthrodesis in Charcot's osteoarthropathy. At the preoperative stage, according to the radiograph of the foot, the bisector of the angle adjacent to the Hissan angle of the calcaneus is measured. Access is performed, scar tissue is excised, destroyed bone and cartilage elements of the talus calcaneus and tibia are removed. Resection of the articular surfaces of the distal metaepiphysis of the tibia and calcaneus is performed. The sawdust of the tibia is performed at an angle in the oblique-horizontal plane, open from front to back, corresponding to the bisector of the angle adjacent to the calcaneus Hissan's angle. The selected bone fragment is moved by 180 degrees and placed in the area of ​​calcaneal-tibial diastasis. The foot is fixed in a functionally correct position with an external fixation device to control the sufficiency of compression between the fragments and the degree of the arthrodesis zone.

EFFECT: method provides restoring the support of the foot, reducing the relative shortening of the operated segment, with the possibility of intraoperative displacement of the foot from front to back without reducing the contact area by performing a one-stage calcaneotibial arthrodesis with preoperative measurement of the bisector of the angle adjacent to the Hissan angle of the calcaneus.

1 cl, 10 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for surgical treatment of complete destruction of the talus in Charcot's osteoarthropathy.

Charcot's diabetic neuroosteoarthropathy is a complication of diabetes mellitus and manifests itself in the form of sensorimotor and autonomic neuropathy, trauma and metabolic bone disorders (Rogers LC, Frykberg RG, Armstrong DG, Boulton AJ, Edmonds M, Van GH, Hartemann A, Game F, Jeffcoate W, Jirkovska A, Jude E, Morbach S, Morrison WB, Pinzur M, Pitocco D, Sanders L, Wukich DK, Uccioli L. The Charcot foot in diabetes. . In lesions of the hindfoot with Charcot neuroosteoarthropathy, which corresponds to the Sanders classification 4-5 (The results of operative treatment of displaced intra-articular calcaneal fractures using a CT scan classification / R. Sanders, P. Fortin, A. DiPasquale [et al. ] In: Tscherne H., Schatzker J. Major fractures of the pilon, the talus and the calcaneus - Berlin, Heidelberg, New York: Springer Verlag, 1992 - P.175-194.), the presence of distal neuropathy, patients often continue walk with full or partial load on the affected segment, which leads to isolated pathological fractures of the talus. The emerging total and subtotal defects of the talus make it impossible to carry out reconstructive interventions or arthrodesis of the ankle and subtalar joints while maintaining a greater segment length. The technique of performing calcaneotibial arthrodesis remains an urgent problem not only because of concomitant osteopenia, vitamin D hypovitaminosis in patients of this category, but also due to delayed consolidation, lack of congruence of the ends of the adaptable tibia and calcaneus. The magnitude of the resulting relative shortening of the limb corresponds not only to the height of the talus, but also to the height of the resected ends of the tibia and, to a greater extent, the calcaneus, necessary to make the fragments congruent.

The literature describes various methods of surgical treatment and performing arthrodesis of the ankle joint in aseptic necrosis of the talus, as well as performing three-articular arthrodesis in Charcot osteoarthropathy. The method of calcaneotibial arthrodesis using the method of blocked osteosynthesis (Klaue K., Zwipp H., Mittlmeier T., Espinosa N. Internal circular arc osteosynthesis of tibiotalocalcaneal arthrodesis. Unfallchirurg. 2016 Oct; 119(10): 885-889. doi: 10.1007/s00113-016-0210-4 [Article in German]). Despite the one-stage correction of the deformity, the remaining shortening required either a subsequent second stage of surgery to correct the shortening, or the manufacture of individual orthopedic shoes with a higher sole height.

The use of free bone grafting in one-stage calcaneotibial arthrodesis using an autograft on a vascular pedicle (RU 2545984 C1) significantly increases the volume of the surgical intervention itself, requires the availability of a microsurgeon and the necessary instruments on staff, which may not always be applicable.

Good results of single-stage bone grafting with autografts are described by foreign colleagues (Technique for Use of Trabecular Metal Spacers in Tibiotalocalcaneal Arthrodesis With Large Bony Defects Christopher Kreulen, Evan Lian, Eric Giza, Foot & Ankle International® 2017, Vol.38(1) 96-106 © The Author(s) 2016). This technique also leads to an increase in the volume of the surgical intervention itself and the fixation time, which requires the restructuring of the autograft.

The active use of a heterotopic allograft with one-stage arthrodesis with intramedullary fixators is repeatedly described in articles by foreign colleagues (Talectomy as Part of Chronic Foot and Ankle Deformity Correction Procedure: A Retrospective Review, Travis M. Langan, DPM, Trapper A.J. Lalli, MD, Clair N. Smith, MS, Dane K. Wukich, MD, Foot and ankle surgery, 2019, DOI: 10.1053/j.jfas. 2019.05.002), with hybrid fixation with extra focal osteosynthesis and intramedullary fixators (Retrograde Intramedullary Nail With Femoral Head Allograft for Large Deficit Tibiotalocalcaneal Arthrodesis , Bradly Bussewitz, DPM, J. George DeVries, DPM Michael Dujela, DPM, Jeffrey E. McAlister, DPM, Christopher F. Hyer, DPM, MS, and Gregory C Berlet, MD, Foot & Ankle International, 2014, Vol.35 (7) 706-711 DOI: 10.1177/1071100714531231), PRP injection at the time of allograft insertion (A Novel Surgical Technique for the Management of Massive Osseous Defects in the Hindfoot with Bulk Allograft, Brian E. With lowers, MD, Mark S. Myerson, Foot Ankle Clin N Am 16 (2011) 181-189, doi: 10.1016/j.fcl.2010.12.005) and the use of an orthotopic allograft (Tibiotalocalcaneal arthrodesis with distal tibial allograft for massive deficits in the ankle, Mario I. Escudero et all, Foot and ankle surgery, 2018, https://doi.org/10.1016/jfas.2018.02.007). The method of bilocal sequential calcaneotibial arthrodesis with an external fixation device under experimental conditions is described by Russian colleagues (RU 2701125 C1). Two-stage methods of arthrodesis with defect plasty with a free autograft (RU 2776414 C1) have significantly more advantages for correcting the relative shortening of the segment and the timing of autologous bone integration, but require the second stage of surgical intervention with longer fixation times. The use of additive technologies to replace talus defects in calcaneotibial arthrodesis using titanium is also actively used in patients with this pathology (Treatment of Severe Avascular Necrosis of the Talus Using a Novel Keystone-Shaped 3D-Printed Titanium Truss Implant, Eamon Ramhamadany, Carolyn Chadwick, Mark B. Davies,

Foot & Ankle Orthopedics 2021, Vol. 6(4) 1-9, DOI: 10.1177/24730114211043 516).

The closest analogues from the field of technology have not been identified.

The task of surgical treatment of patients with complicated diabetic neuroosteoarthropathy is to radically eliminate the focus of bone tissue destruction by surgery and restore the functionality of the foot by reconstructing its anatomical structure, restoring the length of the segment and biomechanics. A large number of ways to solve this problem indicates its relevance.

The technical result achieved by using the present invention is the creation of bone ankylosis in the area of the calcaneal-tibial arthrodesis with simplified adaptation of incongruent surfaces of the calcaneus and distal metaepiphysis of the tibia.

The specified technical result is achieved by the fact that at the stage of preoperative planning, the angle adjacent to the Hissan angle is measured and its bisector is measured. Intraoperatively, the articular surfaces of the tibia and calcaneus are resected, fragments of the destructed talus are removed. Next, sawdust of the distal metaepiphysis of the tibia is made in the oblique-horizontal plane at an angle open from front to back and equal to the preoperatively measured value. The resulting triangular bone fragment is rotated 180 degrees and the bone fragments are adapted in the external fixation apparatus. Fixation continues until complete realignment and radiological signs of consolidation.

The proposed method of surgical intervention allows, with complete destruction of the talus in Charcot osteoarthropathy, to reduce the relative shortening of the lower limb during calcaneal-tibial arthrodesis and more convenient, simple adaptation of the surfaces of the calcaneus and tibia that are discongruent to each other. And despite the incomplete replacement of the segment shortening, the method is simple to perform, does not require the second stage of surgical intervention, does not increase the time for fixing the segment and additional costs for filling the defect with an allo-(auto)graft. This significantly simplifies the orientation of the foot in the sagittal plane, which reduces the time of the intervention.

The invention is illustrated by illustrations, which show:

Fig. 1 - measurement of the angle adjacent to the Hissan's angle of the calcaneus and determination of its bisector, performed at the stage of preoperative planning.

Fig. 2 is an illustration of a foot with a destructively altered talus.

Fig. 3-schematic representation of the sawdust level of the articular surfaces of adaptable bones.

Fig. 4 - image of the bones after sawdust.

Fig. 5 - formation of a bone wedge of the tibia.

Fig. 6 - turn of the bone fragment by 180 degrees.

Fig. 7 - adaptation of the foot in a functionally advantageous position.

Fig.8 - radiograph of the patient in the lateral projection before surgery.

Fig. 9 - intraoperative image intensifier tube after reversal of the bone fragment.

Fig. 10 - radiographs after surgery.

The method is carried out as follows.

At the stage of preoperative planning measure the angle adjacent to the angle of Gissan and measure its bisector (figure 1).

Intraoperatively, with the patient in the supine position, after treatment of the surgical field with antiseptics, a tourniquet is applied to the thigh and access to the ankle joint is performed using Kocher access with resection of the lateral malleolus. Revision of the destruction zone (figure 2), removal of parts of the deformed and affected parts of the talus, scar tissues and pathological granulations, resection of the cartilage of the articular surfaces of the bones (figure 3,4) and synovectomy are carried out. Then, extrafocal osteosynthesis is performed with a compression-distraction external fixation apparatus, consisting of two rings fixed on the lower leg, as well as two half-rings on the foot: one half-ring is installed in the back of the foot and one on the forefoot. In the projection of the rings and half rings, the spokes are drawn in the oblique frontal plane, the spokes are fixed in the plane of the rings and tightened with a spoke tensioner. The half rings are interconnected by threaded rods and one-two-plane hinges. Next, a sawdust of the distal metaepiphysis of the tibia is made in the oblique horizontal plane at an angle of the bisector, open posteriorly and equal to the preoperatively measured value (Fig. 5). The resulting triangular bone fragment is rotated 180 degrees (Fig. 6) and the bone fragments are adapted (Fig. 7) in the external fixation apparatus.

The sutures are removed 3-4 weeks after the operation. Staged x-ray control is carried out every 1-1.5 months. The dismantling of the external fixation device is carried out when obvious radiographic signs of consolidation are detected and after a clinical test is performed. The hardware fixation of the foot is replaced by fixation with a posterior plaster splint for a period of 2-3 weeks - until the wounds heal in the places of the removed fixing elements. In the future, the patient is recommended to wear individual orthopedic diabetic shoes.

The proposed method is illustrated by a clinical example.

CLINICAL EXAMPLE

Patient Ya., 64 years old, type 2 DM was diagnosed 4 years ago. In 2021, he noted the appearance of a deformity of the left foot, was observed on an outpatient basis, and was treated conservatively. Against the background of increasing deformity, repeated opening of phlegmon of the left leg and foot. On admission to the department, radiographs (Fig. 8) showed destruction of the talus. When walking with a load, the varus deformity of the foot increased with a complete violation of the support ability of the limb. At the stage of preoperative planning, the value of the angle of the bisector, equal to the angle of sawing, was determined, intraoperatively, osteosynthesis of the segment was performed with an external fixation device. After debridement and removal of fragments of the talus with preservation of the head of the latter, sawdust of the distal metaepiphysis of the tibia and calcaneotibial arthrodesis with an inverted wedge were performed. The wound was sutured in layers, without drainage. In the postoperative period, stage radiographs were performed (Fig. 10). Fixation in the apparatus continued until radiological signs of consolidation. After dismantling the apparatus, fixation with a TCC plastic bandage was carried out.

Claims (1)

A method for calcaneotibial arthrodesis in Charcot's osteoarthropathy, which consists in taking measurements at the preoperative stage according to the radiograph of the foot, the bisector of the angle adjacent to the calcaneus angle of Gissan, intraoperative access and excision of scar tissue, removal of the destroyed osteochondral elements of the talus calcaneus and tibia, then, the articular surfaces of the distal metaepiphysis of the tibia and calcaneus are resected, the sawdust of the tibia is performed at an angle in the oblique-horizontal plane, open from front to back, corresponding to the bisector of the angle adjacent to the Hissan angle of the calcaneus, the selected bone fragment is moved by 180 degrees and placed into the area of calcaneal-tibial diastasis, the foot is fixed in a functionally correct position with an external fixation device to control the sufficiency of compression between the fragments and the degree of the arthrodesis zone.

Images