RU2791267C1 - Method for applying an apparatus of external fixation in treatment of diaphyseal fractures of the lower leg bones - Google Patents

Abstract

FIELD: traumatology.

SUBSTANCE: treatment of diaphyseal fractures of the lower leg bones in traumatology. The apparatus of external fixation is mounted on two base external supports, each of which is mounted on one spoke, drawn perpendicular to the axis of the proximal and distal fragments of the tibia in the frontal plane. Under X-ray control, distraction is carried out along the rods connecting the base external supports until the displacement of bone fragments along the length is eliminated. In each bone fragment, perpendicular to the fracture plane, one intraosseous threaded rod is inserted, which is fixed on the base supports using external brackets. The final reposition of the bone fragments in the lateral view is performed by moving the outriggers along the annular supports, and in the anteroposterior view, by moving the fastening nuts of the threaded rods in the outboard brackets, while performing counter-lateral compression. In the metaphyses, the fragments are carried along the second spoke, which is fixed on the corresponding base supports, with a crossover relative to the first spokes.

EFFECT: reduction of terms of surgical and inpatient treatment, reduction of traumatism of interventions, improvement of the patient's quality of life during the fixation period by reducing the weight and size of the applied apparatus of external fixation.

1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, traumatology, and is intended for the treatment of diaphyseal fractures of the leg bones.

A known method of transosseous osteosynthesis of diaphyseal fractures of the lower leg according to the method of G.A. Ilizarov (Osteosynthesis of closed fractures of the bones of the lower leg with the Ilizarov apparatus. Method, recommendations / Comp.: G.A. Ilizarov, A.A. Devyatoe, B.K. Konstantinov. - Kurgan, 1976. - 46 p. [1]; Extrafocal compression - distraction osteosynthesis: teaching aid / E.R. Makarevich, A.V. Martinovich, I.I. Dovgalevich. - Minsk: BSMU, 2018 - 35 pp. [2]. of four rings, of which the distal and proximal supports are basic, mounted on pairs of mutually intersecting wires, and two intermediate - repairing supports.In the base supports, located at the level of the metaphyseal parts of the bone, a pair of mutually intersecting wires is carried out at an angle of 60-90 ° In repositioning supports, which are located in close proximity to the level of the fracture, they are carried out along a needle with a thrust platform, due to which the final reposition of the fragments occurs.

However, this method has a number of disadvantages. So, in the case of carrying out two wires on the base supports with technical errors, without observing the angle of 90 degrees relative to the plane of the fracture of the bone, it will lead to difficulty in repositioning bone fragments. In addition, the introduction of the pins in the metaphyseal sections at an angle of mutual decussation of 60-90° leads to the stitching of soft tissues in places where their thickness and displacement, during movements in the adjacent joint, are greater than in other positions at this level of transosseous elements insertion. This leads to traumatization of soft tissues and dangerous development of transfixation contractures and infectious complications. Due to the layout of the device, the gradual removal of the wires, for the "education" of the regenerate at the end of the fixation period, does not involve the gradual removal of external supports. Therefore, throughout the entire period of fixation, a cumbersome arrangement of four rings is maintained, which makes it difficult to start loading the limb early and prolongs the period of fragment consolidation.

The closest to the proposed invention is a method for the treatment of fractures of the bones of the lower leg according to the patent of the Russian Federation No. 2302835 A61V 17/56, Bull. No. 20, 2007 [3]. According to this method, one wire is passed through the metaphyses of fragments in the frontal plane, on which a distraction-reposition device is mounted, the wires are fixed in the rings of the device and coarse axial and rotational displacements are eliminated. Inside the distraction-reposition device, the AVF is mounted, fixing the extreme supports of the apparatus to the previously installed pins. In each fragment, perpendicular to its axis, a threaded rod is introduced parafracture, which is attached to the apparatus supports. After the final reposition, compression is created at the level of the fracture.

The layout of the apparatus of four rings in children is of limited use, as they are bulky and heavy, which increases the rehabilitation period. More G.A. Ilizarov, in the treatment of fractures of the bones of the lower leg in children, proposed to get by with a two-ring layout of the apparatus, since the replacement of heavy repositioning supports of the apparatus with outriggers reduces the weight of the structure by half.

Preliminary elimination of displacement of fragments along the length using a two-section annular apparatus with supports of large diameters, in our opinion, is inconvenient in work, since it is necessary to mount an external fixation device with annular supports of a smaller diameter inside the distraction-reposition device. These manipulations increase the time of the operation, prolong the time of general anesthesia, and make it difficult to process the surgical field.

The use of an excessive number of intraosseous threaded rods on the base supports instead of wires, and the proposed arrangement uses 4 rods, is also undesirable in childhood, since it increases the trauma of osteosynthesis, increases the risk of infectious complications and contractures.

The essence of the invention consists in a combination of essential features sufficient to achieve the desired technical result, which consists in creating a method that allows to reduce the period of surgical and inpatient treatment, by reducing the weight and size of the applied AVF, while reducing the trauma of interventions, and improving the quality of life of the patient during fixation period.

The essence of the method of applying an external fixation device in the treatment of diaphyseal fractures of the bones of the leg includes the reposition of fragments, and their fixation using an external fixation device. The apparatus is mounted on two base external supports, each of which is mounted on one spoke. The needles are carried out perpendicular to the axis of the corresponding proximal, or distal, fragment of the tibia in the frontal plane. Under X-ray control, distraction is carried out along the rods connecting the base external supports until the displacement of bone fragments along the length is eliminated. In each bone fragment, perpendicular to the fracture plane, one intraosseous threaded rod is inserted, which is fixed on the base supports using external brackets. The final reposition of the bone fragments in the lateral view is performed by moving the outriggers along the annular supports, and in the anteroposterior view, by moving the fastening nuts of the threaded rods in the outboard brackets, while performing counter-lateral compression. In the metaphyses, the fragments are carried along the second spoke, which is fixed on the corresponding base supports, with a crossover relative to the first spokes.

Mounting the device on the basis of two basic external supports allows reducing the dimensions and weight of the device without losing its rigidity, which provides early loading on the injured limb, faster fusion of bone fragments, and rehabilitation of patients. The installation of each base support on one spoke, drawn perpendicular to the axis of the corresponding bone fragment in the frontal plane, allows for the primary reposition of fragments in the anteroposterior and lateral directions, and to eliminate their displacement along the length.

The installation of intraosseous threaded rods in each bone fragment perpendicular to its axis and the plane of its fracture is the most biomechanically justified direction to ensure reposition and counter-lateral compression.

Carrying out the final reposition of the bone fragments in the proposed sequence, starting from the lateral view, moving the outriggers along the base, ring supports, and then in the anteroposterior view, moving the nuts along the intraosseous threaded rods, creating a counter-lateral compression of bone fragments, avoids displacement of the fragments. With the reverse sequence of actions, the achieved reposition will be violated, since when the outriggers move along the annular support of the device, the distance from the fixation point of the intraosseous threaded rod in the bone fragment to the center of the next hole in the base ring changes.

Conduction of the second spokes on the proximal and distal base supports is performed after achieving a complete reposition of the fragments. This ensures the stability of the fixation of the base supports of the apparatus, and bone fragments, with the possibility of implementing an early dosed load on the operated limb segment already on the 4th day after the operation. The use of a minimum number of fixing elements (4 spokes and 2 rods) during installation reduces trauma to the limb.

The method of applying the external fixation device in the treatment of diaphyseal fractures of the bones of the lower leg is explained by illustrations, where:

In FIG. 1 shows a diagram of the initial passage of pins 1 and 2, perpendicular to the axis of bone fragments A and B, in the frontal plane, for their fixation on the distal and proximal base supports;

In FIG. 2 - diagram of the threaded rods 8 and 9, where the axis of each of the rods is directed perpendicular to the fracture plane of the corresponding bone fragment A or B, for the implementation of the counter-lateral compression;

In FIG. 3 - general view of the used design of the AVF; In FIG. 4, fig. 5, fig. 6 shows illustrations explaining a clinical example, where:

In FIG. 4 - x-rays of the left limb of the patient I-voi, 7 years old, upon admission to the clinic;

In FIG. 5, - x-rays of the limb of the patient I-voi, 7 years after the application of the apparatus.

In FIG. 6-a and 6-b - functional result of treatment of patient I-voi, 7 years old, 30 days after discharge from the clinic. The apparatus is used as follows.

Preliminary reposition is performed, as a rule, on an orthopedic table, taking into account the restoration of the biomechanical axis of the damaged segment, passing through the anterior-superior axis of the iliac wing, the middle of the patella, and the gap between the first and second toes. Spend one needle 1 and 2 on the distal A, and proximal B, metaphyses of the tibia in the frontal plane, the direction of which is perpendicular to the axis of the fragments. After fixing the spokes, with the help of spoke fixators 3, in the base ring supports 4 and 5, the displacement along the length is eliminated by moving the standard nuts 6 along the threaded rods 7 connecting the base ring supports 4 and 5. In bone fragments A and B, one intraosseous threaded rod 8 and 9 (Fig. 2), which are located in the immediate vicinity of the fracture line, perpendicular to the fracture plane, and its fracture line, and are fixed with the help of external brackets 10 and 11. The final reposition of bone fragments in the lateral projection is performed by moving the external brackets 10 and 11 in the holes of the annular supports 4 and 5, and in the anterior-posterior projection - by moving the nuts 12, fastening the intraosseous threaded rods 8 and 9, in the outriggers 10 and 11, while simultaneously performing the counter-lateral compression of the bone fragments. It is carried out along the second spoke 13 and 14 on the corresponding base annular supports 4 and 5, with the maximum possible crossover relative to the first spokes 1 and 2.

Clinical example.

Patient Iva, 7 years old, was admitted to the clinic with a diagnosis of Closed oblique fracture of the middle third of both bones of the left leg (Fig. 4). After preoperative preparation and general anesthesia, the patient's limb was placed on an orthopedic table, taking into account the restoration of the biomechanical axis of the damaged segment, passing through the anterior-superior axis of the iliac wing, the middle of the patella and the gap between the first and second toes. On the distal and proximal metaphyses of the tibia, determining the direction from radiographs, in the frontal plane, one base wire was drawn perpendicular to the axis of the fragments (Fig. 5). The displacement along the length was eliminated by performing distraction along the rods connecting the base supports, and the primary reposition of the bone fragments along the width. In each bone fragment, perpendicular to the plane of the fracture, and the line of its fracture, in the immediate vicinity of this line, one intraosseous threaded rod was inserted. Performed the final elimination of displacement in the anteroposterior and lateral projections. Simultaneously, counter-lateral compression was performed. Threaded rods were fixed on remote brackets, which acted as repositioning-fixation supports of the apparatus. The final reposition of the bone fragments was performed in the lateral view by moving the outriggers in the holes of the base ring supports, and then in the anteroposterior view, twisting and, unwinding, the regular nuts on the intraosseous threaded rods, which also carried out the counter-lateral compression of the bone fragments. In the metaphysis of the fragments, one more spoke was passed, followed by tension and fixation on each base support, with the maximum possible crossover relative to the first spokes (Fig. 5).

An early dosed load on the operated segment of the limb was started on the 4th day after the operation.

The period of inpatient treatment was 6 days. After 30 days, the patient moved independently, without crutches. (Fig. 6, 7). The device was dismantled two months after surgical treatment. The child did not need rehabilitation measures. This is due to the load, and independent walking, already on the 4th day after surgical treatment. The speed of osteosynthesis, low trauma, short hospital stay, and the virtual absence of the need for rehabilitation measures allow us to recommend this method for use in wide clinical practice.

Claims (1)

A method for applying an external fixation apparatus in the treatment of diaphyseal fractures of the bones of the leg, including the reposition of fragments and their fixation using an external fixation apparatus, characterized in that the apparatus is mounted on two base external supports, each of which is mounted on one spoke drawn perpendicular to the proximal axis, and distal, a fragment of the tibia in the frontal plane, under X-ray control, distraction is carried out along the rods connecting the base external supports, until the displacement of the bone fragments along the length is eliminated, one intraosseous threaded rod is inserted into each bone fragment, perpendicular to the plane of the fracture, which is fixed on the base supports using outboard brackets, the final reposition of bone fragments in the lateral projection is performed by moving the outboard brackets along the annular supports, and in the anteroposterior projection - by moving the nuts for fastening the threaded rods in the outboard brackets, while simultaneously inserting river-lateral compression, in the metaphyses of the fragments, is carried out along the second spoke, which is fixed on the corresponding base supports, with a crossover relative to the first spokes.

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