RU2798905C1 - Method of treating bone marrow osteomyelitic cavity - Google Patents

Abstract

FIELD: medicine, orthopedics.

SUBSTANCE: invention can be used in the treatment of patients with chronic osteomyelitis with damage to the bone marrow cavity. When opening the cavity, a longitudinal cut of the bone is made along the affected medullary canal. One of the bone walls is retracted and, after removal of necrotic tissues, longitudinal, congruent, centrally located grooves are formed in the walls, after which the walls are combined, and then one of them is dosed in a width of 0.25 mm twice a day until the required bone thickness is restored. In the presence of shortening, a longitudinal cut of the bone is carried out throughout the affected medullary canal, one of the walls is additionally crossed within healthy tissues at the top of the cut, and the opposite wall is crossed within healthy tissues at the lower pole of the medullary cavity. Then, the fragments are dosed along the length of 0.25 mm twice a day until the required length and thickness of the bone is restored.

EFFECT: method ensures the elimination of the osteomyelitic process and restoration of the integrity, shape, length of the bone due to the features of opening and processing the osteomyelitic cavity, as well as the features of osteosynthesis.

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Description

The invention relates to medicine, in particular to orthopedics, and can be used in the treatment of patients with chronic osteomyelitis with damage to the bone marrow cavity.

Known "Method of compensating the osteomyelitic cavity" according to A.S. USSR No. 1039488 (publ. 07.09.1983 VI No. 33), providing for the implementation of osteotomy directly through the osteomyelitic focus, followed by distraction of bone fragments to suppress the inflammatory process and replace the cavity with a distraction regenerator.

However, when the osteomyelitic focus captures a large part of the bone marrow cavity, the implementation of this technique does not provide complete suppression of osteomyelitis as a purulent-inflammatory process and leads to a relapse of the disease.

Known "Method of replacing the osteomyelitic cavity" according to A.S. USSR No. 1147377 (published on March 30, 1985, VI No. 12). The said method is carried out by opening and treating the osteomyelitic cavity, forming a fragment from one of its walls and its dosed movement in the direction of the opposite wall along the trajectory corresponding to the bone perimeter.

However, this technique also cannot be used in the treatment of osteomyelitis with damage to the bone marrow cavity, especially with subtotal bone damage. It should be borne in mind that with this form of lesion, there is an excessive thickness of the bone walls in combination with a narrowing of the medullary canal, which takes the form of an "hourglass". The consequence of this is a deterioration in the conditions of blood supply to the bone, hematopoiesis, which ultimately, even with radical treatment of the focus of osteomyelitis, adversely affects the relief of the osteomyelitis process as a whole, causing its recurrence. With this pathology, shortening of the limb segment is also possible, and a second stage of treatment will be required to eliminate it.

The prototype of the proposed method can be "Method of replacing a bone defect with the presence of a centrally located osteomyelitic focus in children" (Patent No. 2515685, publ. 20.05.2014.) hematogenous osteomyelitis, when the bone surface is accessed, its affected areas are treated with the removal of non-viable tissues. Osteosynthesis of the affected segment is performed using an external fixation device. Next, from the side of the bottom of the treated cavity, osteoperforation of the adjacent epiphysis is carried out to a depth of the growth zone, and then its integrity is violated. To compensate for the defect, the integrity of the bone is violated both by osteotomy and by intraoperative epiphysiolysis.

However, this method does not eliminate the excess thickness of the bone walls in combination with the narrowing of the medullary canal, which takes the form of an "hourglass", does not allow removing the inner surface of the walls, which are pierced throughout, like a grid, with many small passages filled with pus, sequesters. In addition, in conditions of impaired blood supply, the use of this method is also associated with the possibility of developing postoperative complications.

The objective of the present invention is to develop a method for the treatment of chronic osteomyelitis, which ensures the elimination of the osteomyelitic process and the restoration of the integrity, shape and length of the bone in bone marrow lesions.

The use of the method is illustrated by the following clinical observations and illustrative material, which shows:

Fig. 1 (a, b, c, d) - A method for treating a bone marrow osteomyelitic cavity.

Fig. 2 (a, b, c) - A method for treating a bone marrow osteomyelitic cavity, with shortening.

Fig. 3 (a, b, c) - Radiographs of the patient K. before treatment, during treatment, after treatment.

Fig. 4 (a, b, c, d, e) - Radiographs of the patient G. before treatment, during treatment, after treatment, long-term result.

Disclosure of the invention. A method for the treatment of chronic osteomyelitis in bone marrow lesions (Fig. 1a, Fig. 2a - fistulograms before treatment), including opening and processing of the osteomyelitic cavity throughout its entire length, as well as dosed traction of fragments until the osteomyelitic process is eliminated, the integrity and shape of the bone are restored using the apparatus external fixation. When opening the cavity, a longitudinal cut of the bone is made along the entire length of the medullary canal, one of the walls of the bone is retracted, and after removal of necrotic tissues, longitudinal, congruent, centrally located grooves are formed in the walls, after which the walls are combined, and then one of them is dosed in width by 0 .25 mm twice a day until the required bone thickness is restored (Fig. 1b, c). When the limb segment is shortened, a longitudinal cut of the bone is performed along the entire length of the affected medullary canal, one of the walls is additionally crossed within healthy tissues at the top of the cut, and the opposite wall is crossed within healthy tissues at the lower pole of the medullary cavity, and then the fragments are dosed along the length 0.25 mm twice a day until the required length and thickness of the bone is restored (Fig. 2b).

New in the proposed method is that when opening the cavity, a longitudinal cut of the bone is made along the entire length of the medullary canal, one of the walls of the bone is removed, and after removal of necrotic tissues, longitudinal, congruent, centrally located grooves are formed in the walls, after which the walls are combined, and then dosed move one of them in width by 0.25 mm twice a day until the required bone thickness is restored. When the limb segment is shortened, a longitudinal cut of the bone is performed along the entire length of the affected medullary canal, one of the walls is additionally crossed within healthy tissues at the top of the cut, and the opposite wall is crossed within healthy tissues at the lower pole of the medullary cavity. Then, the fragments are dosed along the length of 0.25 mm twice a day until the required length and thickness of the bone is restored. The above indicates the compliance of the proposed method with the criterion of "novelty".

The method is carried out by the fact that after anesthesia and treatment of the surgical field, soft tissue incision is made throughout the affected diaphysis of the limb segment, providing access to the bone surface with excision of the fistulous passages. A longitudinal cut of the bone is performed along the entire length of the affected medullary canal, making notches on one of the walls at the tops of the cut. After that, one of the walls is taken aside, opening the affected osteomyelitic cavity of the medullary canal. Free-lying sequesters are removed, and then necrotically altered tissues. With chisels and electromills, the walls of the cavity are processed to "bloody dew". Following this, the walls of the cavity are given the required thickness, and the medullary canal is given the required volume, which is carried out by forming longitudinal congruent centrally located grooves, the length of which corresponds to the required length of the medullary canal. After that, the treated walls are combined with each other and a drainage system is installed for constant micro-irrigation of the cavity with antiseptics.

When shortening, a longitudinal cut of the bone is carried out throughout the affected medullary canal, one of the walls is additionally crossed within healthy tissues at the top of the cut, and the opposite wall is crossed within healthy tissues at the lower pole of the medullary cavity. The cavity walls are treated as described above.

The operation is completed with the application of an external fixation device. When applying the apparatus, crossed spokes are passed through the bone (above and below the opened medullary canal) and the retracted wall of the bone (if the task is not to eliminate the length of the limb segment). The spokes in a taut state are fixed on the supports of the apparatus installed at the appropriate level and in traction rods, evenly installed throughout the entire length of the segment.

The supports of the apparatus are interconnected by distraction rods and longitudinally arranged beams. The surgical wound is sutured, control radiography is performed and the apparatus systems are stabilized.

On the fifth-seventh day after the operation, dosed traction of the selected bone wall along the width is started. Traction is performed at a rate of 0.25 mm twice a day until the required bone thickness is restored. Upon reaching the required dimensions of the bone diameter, the device is transferred to the fixation mode, the duration of which is usually about 60 days (Fig. 1d).

With simultaneous restoration of the length of the limb, on the 7-10th day after the operation, dosed traction along the length is started at a rate of 0.25 mm twice a day. Its duration is until the limb length is restored.

After dismantling the device, additional immobilization of the limb is usually not required (Fig. 2c).

Example 1. Patient K., aged 24, diagnosis: Post-traumatic osteomyelitis of the right tibia fistulous form. The duration of the disease is 6 years. X-ray (Fig. 3a) on the fistulogram revealed the spread of the osteomyelitic focus over 12 cm of the medullary canal, the cavity of the medullary canal is narrowed.

To eliminate the osteomyelitic process, the patient underwent an operation: a longitudinal cut of the bone with the release of its wall, removal of necrotic tissues, formation of a cavity in the bone marrow canal, osteosynthesis with external fixation devices (Fig. 3b).

During the operation, after anesthesia and treatment of the surgical field, access to the bone was performed through the tissue incision along the anterior-outer surface of the leg along its entire length of the diaphyseal part with excision of the fistulous passages. With the help of chisels and an apparatus for mechanical processing of the bone, a longitudinal cut of the bone was made along the entire length of the medullary canal with the release of the outer wall of the bone. Taking the latter aside, performed access to the osteomyelitic cavity.

Further, with the help of chisels and electrophoresis, the cavity was treated throughout with the removal of necrotic tissues; the cavity was treated to "bloody dew". Following this, longitudinal centrally located grooves were formed in the walls of the bone, which corresponded in size to each other and, when combined, formed a reconstructive cavity of the medullary canal with a diameter of about 0.5 cm.

At the final stage of the operation, an external fixation device was applied. When it was applied, two pairs of intersecting spokes were passed through the proximal and distal metadiaphyseal regions, which were fixed in the annular supports, connected to each other by threaded rods and longitudinally located beams. The selected fragment in the form of one of the walls of the bone was fixed with traction rods, the ends of which were fixed in rods installed on the beams. At the same time, a drainage system was installed in the cavity of the reconstructed medullary canal.

After performing the control radiography and closing the wound, the apparatus systems were finally stabilized.

Starting from the seventh day after the operation, a dosed displacement of the selected outer wall of the bone along the width was carried out until its required thickness was restored. The drainage microirrigation system was removed on the 8th day after the operation: the fistulas closed after 15 days.

The rate of application of traction forces was 0.25 mm twice a day, the duration was 5 days. The period of subsequent fixation was 63 days. (Fig. 3c.). Additional immobilization after dismantling the apparatus was not performed.

As a result of treatment, the osteomyelitic process was stopped. The anatomical shape of the bone and the medullary canal were restored.

After 2 years, the result of treatment is preserved. Clinically and radiologically, there is a restoration of the integrity of the bone, its structure and shape.

The patient fully loads the operated limb. Works in his specialty.

Example 2. Patient G., aged 33, diagnosis: chronic post-traumatic osteomyelitis of the right thigh of the fistulous form, intracanal type of bone lesion, osteomyelitic cavity 11.0×1.7 cm; shortening of the right thigh 6 cm, extensor contracture of the right knee joint. Disabled group II. The duration of the disease is 3 years. Prior to treatment at the RRC "VTO", the patient was operated on five times, but the fistula continued to function and there was a shortening of the thigh by 6 cm. Pain and lameness were disturbing. The patient walked with crutches, compensating for a shortening of 6 cm. On the right thigh, cicatricial changes in the skin with edema, trophic changes in soft tissues, a fistula with purulent discharge. Movements in the right knee joint 180°/170°. On the fistulogram of the thigh before treatment, the osteomyelitic cavity is 11.0×1.7 cm, the articular space of the knee joint is narrowed, asymmetric (Fig. 4a). Operation: sequestrnecrectomy according to the type of bone resection from the inside with osteotomy through the intracanal located osteomyelitic cavity, osteosynthesis with the Ilizarov apparatus (Fig. 4b). Distraction along the length of 0.25 mm twice a day - 71 days, in combination with traction in the frontal plane of 0.25 mm twice a day for 5 days (Fig. 4c).

The fistula closed, the shortening and edema were eliminated, the bone cavity was replaced, movements in the knee joint were 180°/170°, fixation - 90 days (Fig. 4d).

Long-term result after 3 years (Fig. 4e). There are no fistulas. Movement in the knee joint 180°/160°. Disabled group III. He wears model shoes, does not limp, works in his specialty.

The technical result is achieved by opening and processing the osteomyelitic cavity throughout its entire length, as well as dosed traction of the fragments until the osteomyelitic process is eliminated, the integrity and shape of the bone are restored using an external fixation apparatus. When opening the cavity, a longitudinal cut of the bone is made along the entire length of the medullary canal, one of the walls of the bone is retracted, and after removal of necrotic tissues, longitudinal, congruent, centrally located grooves are formed in the walls, after which the walls are combined, and then one of them is dosed in width by 0 25 mm twice a day until the required bone thickness is restored. When the limb segment is shortened, a longitudinal cut of the bone is performed along the entire length of the affected medullary canal, one of the walls is additionally crossed within healthy tissues at the top of the cut, and the opposite wall is crossed within healthy tissues at the lower pole of the medullary cavity, then the fragments are moved in a dosed manner along the length along 0.25 mm twice a day until the required length and thickness of the bone is restored. The cavity walls are treated as described above. After osteosynthesis with an external fixation device, controlled transosseous osteosynthesis is performed, which allows dosed displacement of fragments until the required length and thickness of the bone is restored.

The use of the method ensures the elimination of the osteomyelitic process and the restoration of the integrity, shape, length of the bone. Thus, the problem of treating one of the most severe forms of osteomyelitic lesions, which previously required lifelong disability, has been solved.

Information sources:

1. A.S. USSR No. 1039488, publ. 09/07/1983 VI No. 33.

2. A.s. USSR No. 1147377, publ. 03/30/1985, VI No. 12.

3. RF patent No. 2515685, publ. 20.05. 2014.

Claims (2)

1. A method for treating a bone marrow osteomyelitic cavity, including opening and processing the osteomyelitic cavity throughout its entire length, as well as dosed traction of fragments until the osteomyelitic process is eliminated, the integrity and shape of the bone are restored using an external fixation apparatus, characterized in that when opening the cavity, a longitudinal cut is made bones along the affected medullary canal, remove one of the walls of the bone and after removal of necrotic tissues in the walls of the bone fragments form longitudinal centrally located grooves that correspond in size to each other and, when combined, form a reconstructive cavity of the medullary canal; bone fragments are moved in a dosed manner along a width of 0.25 mm twice a day until the required bone thickness is restored. 2. The method according to claim 1, characterized in that to restore the length of the limb, a longitudinal cut of the bone is carried out throughout the affected medullary canal, one of the walls is additionally crossed within healthy tissues at the top of the cut, and the opposite wall is crossed within healthy tissues at lower pole of the medullary cavity; simultaneously with dosed traction of the bone fragments along the width, dosed movement of the fragments along the length of 0.25 mm is carried out twice a day until the length of the limb is restored.

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