RU2782997C1 - Combined method for the treatment of scaphoid fractures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics, and can be used for the surgical treatment of fractures of the navicular bone of the radiocarpal joint. Dorsal access to the scaphoid bone, repositioning of bone fragments and their fixation with Herbert's lag screw are performed. After repositioning of the fragments, before their fixation, 1 ml of the stromal-vascular fraction obtained from the adipose tissue of the patient's anterior abdominal wall is injected into the fracture area.

EFFECT: method provides ease of surgical treatment, reduction of treatment time and low risk of complications due to the combination of techniques of the claimed invention.

1 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, specifically to traumatology and orthopedics, and is used in the treatment of fractures of the navicular bone of the wrist joint, in order to improve its results.

Fractures of the navicular bone occupy one of the first places among the injuries of the bones of the hand, and the first place among the injuries of the bones of the wrist. The frequency of this type of damage among all injuries of the bones of the skeleton is 1-7% [1]. Late diagnosis, and subsequent inadequate treatment, lead to the fact that 25% of patients develop false joints. One of the reasons for the development of complications is the peculiarity of nutrition of ⁵ bones of the wrist. Thus, the risk of non-union of a scaphoid fracture is extremely high, since its fracture disrupts the blood supply to the proximal fragment [2].

A known method for the treatment of fractures of the scaphoid bone graft from the ilium. According to this method, during the operation, the scaphoid bone is reamed, an autologous graft and bone marrow are taken from the ilium, with its subsequent introduction into the formed channels of the navicular bone. An external fixator is used to fix the fracture [3]. However, this method has many disadvantages. Performing additional access to the bones of the spongy structure, which have a good blood supply, gives the risk of heavy bleeding, which increases the invasiveness of the operation. The second disadvantage is the method of fixing the navicular bone with an external fixation device. The imposition of this device requires high qualifications of the doctor, the absence of which does not exclude the occurrence of complications in the form of neuropathy of the nerves, since each person has his own peculiarities in the location of the neurovascular bundles.

The closest, in terms of its technical solution, to the proposed method is the method by which the patient performs a dorsal approach to the navicular bone, repositions the bone fragments, and fixes them with a Herbert lag screw [4]. This type of fracture fixation is reliable and easy to use, however, due to poor blood supply to the navicular bone, there is a high risk of fracture failure, and subsequently the screw may migrate, forming a false joint of the bone.

The essence of the invention consists in a set of essential features sufficient to achieve the desired technical result, which consists in ease of implementation, reduction in treatment time, and low risk of complications.

The essence of the combined method for the treatment of scaphoid fractures includes dorsal access to the navicular bone, repositioning of bone fragments, and their fixation with a Herbert lag screw. After repositioning and before the fixation of the fragments, 1 ml of the stromal-vascular fraction obtained from the adipose tissue of the patient's anterior abdominal wall is injected into the fracture area.

The introduction of 1 ml of the stromal vascular fraction (SVF) into the fracture area, with the stem cells contained in it, promotes the formation of a capillary network around the injection site, faster formation of soft bone callus, and subsequently, the healing of the fracture [5]. Adipose tissue contains a huge number of blood vessels, the destruction of which occurs during the preparation of SVF - disassembly of the vascular network. With the introduction of SVF into the damaged area, the disconnected cells of the vascular wall are able, together with the existing blood vessels, to create a hybrid vascular network - assembly. Macrophages obtained by isolating SVF from adipose tissue have an anti-inflammatory phenotype (M2) and may also play a role in reducing inflammation [6].

The introduction of the stromal-vascular fraction before osteosynthesis makes it possible to irrigate the spongy part of the navicular bone in the fracture zone, which is not accessible after osteosynthesis.

The illustrations explain the clinical example where:

On FIG. 1 - radiograph of the wrist joint of Patient M. upon admission;

On FIG. 2 - intraocular image of a fracture of the navicular bone;

On FIG. 3 - intraoperative image of fixation of the fracture with Herbert's screw;

On FIG. 4 - radiograph of the wrist joint of patient M. after surgery;

In FIG. 5 - radiograph of the wrist joint of patient M. 5 weeks after surgery.

The method is carried out as follows.

At the stage of preparation of the operation, adipose tissue is taken from the anterior abdominal wall of the patient. To do this, an incision about 5 mm in size is made below the navel. Using a cannulated liposuction needle, a mixture of anesthetic solution with adrenaline in the amount of 60 ml is injected through this incision. After the introduction of the solution, using the same needle, fat is taken, which contains the stromal-vascular fraction. The resulting mixture of fat aspirate is poured into a special test tube with a cone-shaped bottom and subjected to centrifugation for 5 minutes, as a result of which the mixture separates. At the same time, fat cells appear in the upper part, and stem cells of the stromal-vascular fraction, which are withdrawn from the test tube with a syringe, are located below.

After receiving the stem cells of the stromal-vascular fraction, they proceed to the actual surgical treatment, for which a dorsal approach to the navicular bone is performed. By means of a flexion movement in the wrist joint, the navicular bone is repositioned. The previously obtained solution of the stromal-vascular fraction in the amount of 1 ml is introduced into the fracture area, a carpal pin is passed across the scaphoid bone and a Herbert screw is installed using a hollow screwdriver.

With all the variety of labels for obtaining the stromal-vascular fraction, this technique was chosen by us because of its availability and the possibility of obtaining a stable result of cell concentrations. The removal of cells from the subcutaneous fat of the anterior abdominal wall is a low-traumatic method for obtaining the patient's adipose tissue. At the stage of solution administration, a cannulated needle is needed for deeper access to the areas of the anterior abdominal wall, anesthetic solution and adrenaline can reduce pain and bleeding. The solution volume of 60 ml was selected empirically, it allows to obtain 20 ml of a mixture of fat cells, which, in turn, is equal to the volume of the test tube for obtaining the stromal-vascular fraction, from which 1 ml of the stromal-vascular fraction is obtained. The advantage of the method is its simplicity, shortening of treatment time, and low risk of complications.

Clinical example.

Patient M., 2 months before the visit, was injured at home, a plaster splint was applied to him in the emergency room, and 1.5 months after the removal of the plaster splint, an ununited fracture of the navicular bone was found on the control radiography (Fig. 1).

For a period of 2 months after the injury, the patient was admitted to the Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, where he was treated according to the proposed method. Under local anesthesia, a dorsal approach to the navicular bone was performed, in which its fracture was well visualized (Fig. 2). A solution of the stromal-vascular fraction in the amount of 1 ml, previously obtained from the adipose tissue of the patient's anterior abdominal wall, was introduced into the fracture area, a carpal pin was passed across the scaphoid bone and, using a hollow screwdriver, the Herbert screw was installed (Fig. 3), a control radiograph was performed (Fig. 4). On examination after 5 weeks, good consolidation of the fracture is visible (Fig. 5). Such an X-ray picture, in the absence of the use of the stromal vascular fraction, occurs only for a period of 3 months after the operation.

Sources of information

1. Slade JF, Lozano-Calderon S, Merrell G, Ring D. Arthroscopic-assisted percutaneous reduction and screw fixation of displaced scaphoid fractures. J Hand Surg Eur Vol. 2008 Jun; 33(3):350-4. doi: 10.1177/1753193408090121. PMID: 18562371.

2. Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004 Sept;70(5):879-84. PMID: 15368727.

3. RF patent №2640088 method of surgical treatment of false joints of the navicular bone of the hand.

4. Nettov G.G. TREATMENT OF NON-UNITED FRACTURES OF THE NAVOID BONE OF THE HAND // Medicine of Kyrgyzstan. 2011. No. 4.

5. Hatazawa Υ, Ono Y, Hirose Υ, Kanai S, Fujii NL, Machida S, Nishino I, Shimizu T, Okano M, Kamei Y, Ogawa Y. Reduced Dnmt3a increases Gdf5 expression with suppressed satellite cell differentiation and impaired skeletal muscle regeneration . FASEB J. 2018 Mar;32(3): 1452-1467. doi: 10.1096/rj.201700573E. Epub 2018 Jan 3. PMID: 29146735.

6. E. R. Gatiatulina, N. E. Manturova, T. P. Dimov, V. C. Vasiliev, and Zh. Stromal-vascular fraction of adipose tissue: mechanism of action, prospects and risks of topical application. Plastic surgery and aesthetic medicine. 2019;2:43-48. https://doi.org/10.17116/plast.himrgia261902143.

Claims (1)

A method for the combined treatment of fractures of the scaphoid bone, including a dorsal approach in the area of the wrist, repositioning of bone fragments and fixing them with a Herbert lag screw, characterized in that after repositioning and before fixing the fragments, 1 ml of stromal-vascular fraction obtained from adipose tissue is injected into the fracture area anterior abdominal wall of the patient.

Images