RU2801422C1 - Method for lengthening toe phalanx in case of brachiphalangia using an autograft - Google Patents

Abstract

FIELD: medicine, surgery and orthopaedics.

SUBSTANCE: invention can be used to lengthen the toe phalanx in brachiphalangia using an autograft. A lateral exposure is performed longitudinally in the proximal direction parallel to the phalanx of the finger to the level of the proposed osteotomy. The site of osteotomy is exposed in layers, the proximal metaepiphysis and the middle third of the diaphysis of the phalanx are isolated at the site of osteotomy. A transverse osteotomy is performed: the saw blade is set parallel to the frontal plane of the phalanx at a distance of 0.5 cm from the articular cartilage line of the metatarsophalangeal joint from the rear to the sole of the foot, the saw blade is placed at an angle of 90° to the horizontal axis of the metatarsal. Graft is sampled from the diaphysis of the proximal phalanx of the 5th toe. Lateral exposure is performed parallel to the proximal phalanx of the finger in the projection of the proposed osteotomy, the diaphysis of the proximal phalanx is isolated, the first osteotomy is performed proximally 0.5 cm from the border of the articular cartilage, the saw blade is oriented perpendicular to the proximal phalanx from the outside inwards. The distance required for the graft is receded distally, the second osteotomy is performed parallel to the first, so that a cylindrical graft is obtained. The graft is placed in saline, NaCl 0.9%. Two segments of the diaphysis are installed parallel to each other. The pin is passed through the base of the proximal phalanx, the entry point of the pin is located on the outside of the phalanx. The pin is oriented into the medullary canal to the distal edge of the phalanx. The cortical layer is reamed to the chondral layer of the distal segment of the phalanx. The fragments are fixed by passing a cannulated, self-reaming, compressing screw, which is inserted along a previously installed pin. The graft is placed in the area of the previously performed osteotomy of the proximal phalanx of the shortened finger, restoring the alignment of the proximal, distal fragments and the graft. Transarticular fixation of the osteotomy is performed using a 1 mm Kirschner wire, passing it percutaneously through the distal phalanx in the direction of the metatarsal head. Reaming with a cannulated drill along the wire through the distal phalanx up to 6-7 cm in the medullary canal of the metatarsal bone is performed, fixing the fragment in the area of the proposed fusion.

EFFECT: method provides reduction of period of treatment and rehabilitation due to one-stage elimination of defect of bone shortening of finger phalanx.

1 cl, 4 dwg, 2 ex

Description

The invention relates to medicine, namely to orthopedics, and can be used in the treatment of deformities of the musculoskeletal system and structures that provide strong fixation of bones.

State of the art

Brachyphalangia is a congenital or acquired shortening of the phalanges of the toes, accompanied by a change in the length of the fingers in the parabola, which is manifested by a cosmetic defect and discomfort when choosing shoes.

Several generally accepted surgical correction techniques have been proposed for the treatment of this pathology. Dr. André Perin Shecaira in Brachymetatarsia: One-stage Versus Two-Stage Procedures. 2019 Dec;24(4):677-687. describes a technique for simultaneous lengthening of the metatarsal bone using a plate and screws. The technique consists in performing a transverse osteotomy of the metatarsal bone through the dorsal approach. Next, a graft is taken from the tibia or iliac crest. The graft is placed in place of the previously performed osteotomy of the metatarsal bone. The graft is fixed with a plate and screws. However, this technique has a high complication rate - 19.48% (André PerinShecaira, Rodrigo Mota PachecoFernandes), such as metal fixator migration, graft lysis, metatarsal head subluxation, peri-implant fractures.

There is also a similar technique using an external fixator rod proposed by Dr. Mario Fuiano et al (Callus distraction with external fixator for the treatment of congenital brachymetatarsia of the fourth ray August 2020, Pages 693-698). The article describes the method of distraction lengthening using the MiniRail System M103 (Orthofix, Bussolengo). Under fluoroscopic control, pins were placed on the dorsolateral surface of the fourth metatarsal at an angle of 45° to the frontal plane, two in the proximal metaphysis and two in the distal metaphysis. After fixation with pins, a dorsal approach was performed in the projection of the middle third of the metatarsal shaft. Then, a transverse osteotomy was performed perpendicular to the longitudinal axis of the metatarsal bone using an oscillating saw in the middle third of the metatarsal shaft. After 7 days from the moment of compression at the site of osteotomy, the callus is elongated at a rate of 0.5 mm/day. This technique has a number of significant disadvantages, such as: a long period of distraction, which requires frequent monitoring by a doctor and causes psychological discomfort for the patient, the risk of infectious complications at the site of the pin insertion, stiffness in the metatarsophalangeal joint after dismantling the apparatus.

There is a known method of simultaneous lengthening of the metatarsal bone in brachymetatrsia using an autograft (RU 2711237 C1, publ. 15.01.2020). The method consists in dorsal access in the projection of the 4th metatarsophalangeal joint, transverse osteotomy of the metatarsal bone is performed. Next, a fence is made from the 5th metatarsal bone through an additional rear access, sawing out a cylindrical fragment with fixation of the osteotomy site with a cannulated screw. Next, the resulting graft is installed at the site of osteotomy of the 4th metatarsal bone. The graft is fixed with a cannulated screw. Then layer-by-layer suturing of the postoperative wound is performed. In the postoperative period, special shoes are used with unloading of the forefoot. The disadvantage of the known method is that when the graft is fixed with a permanent metal fixator, the risk of graft lysis increases. In this case, the known method was not used when lengthening the phalanges of the fingers.

Disclosure of invention

All known methods did not allow to achieve the expected clinical result in a short time, but required long-term treatment, which was manifested by severe stress and discomfort for the patient.

The technical result consists in increasing the efficiency of the method for lengthening the phalanx of the toe in brachiphalangia using an autograft due to its implementation in one stage, i.e., to one-stage elimination of the bone shortening defect of the phalanx of the toe, which ultimately allows to significantly reduce the time of treatment and rehabilitation.

Implementation of the invention

The technical result is achieved due to the fact that the method of lengthening the phalanx of the toe in brachyphalangy using an autograft includes osteotomy of the proximal phalanx, while performing a lateral lateral access longitudinally in the proximal direction parallel to the phalanx of the finger to the level of the proposed osteotomy, exposing the site of osteotomy in layers, highlighting the diaphysis of the phalanx in at the site of the osteotomy, transverse osteotomy is performed, the saw blade is set parallel to the frontal plane of the phalanx at a distance of 0.5 cm from the articular cartilage line of the metatarsophalangeal joint from the rear to the sole of the foot, while the saw blade is placed at an angle of 90 degrees to the horizontal axis of the metatarsal bone, then the stage of graft sampling from the proximal phalanx of the adjacent finger, a lateral lateral approach is performed parallel to the proximal phalanx of the finger in the projection of the proposed osteotomy, the diaphysis of the proximal phalanx is isolated in layers, the first osteotomy is performed proximally 0.5 cm from the border of the articular cartilage, the saw blade is oriented perpendicular to the proximal phalanx from the outside inwards, then a ruler is applied parallel to the phalanx of the finger and the distance necessary for the transplant is receded distally, the second osteotomy is performed parallel to the first, so that a cylindrical transplant is obtained, the resulting transplant is dipped in a saline solution, NaCl 0.9%, then two segments of the diaphysis are installed parallel to each other , perform temporary fixation of osteotomy of the finger phalanx with a 1 mm Kirschner wire, pass the wire through the base of the proximal phalanx, place the entry point of the wire on the outside of the phalanx, orient the wire into the medullary canal to the distal edge of the phalanx, ream the cortical layer with a cannulated drill to the chondral layer of the distal segment of the phalanx, then, the fragments are fixed by passing a cannulated, self-reaming, compression screw, which is inserted along the previously installed needle, then the resulting graft is placed in the area of the previously performed osteotomy of the proximal phalanx of the shortened finger, while the distal segment is moved until the alignment of the proximal, distal fragments of the osteotomy and the graft is restored, then transarticular fixation of the osteotomy is performed using a 1 mm Kirschner wire, the wire is passed percutaneously through the distal phalanx, orienting the wire in the direction of the head of the metatarsal bone, then the needle is reamed with a cannulated drill through the distal phalanx in the direction of the medullary canal of the metatarsal bone, reamed up to 6-7 cm in the medullary canal of the metatarsal bone, thereby fixing the fragment in the area of the proposed fusion.

The invention is illustrated by X-ray photographs, which show examples of brachaphalangy FIG. 1 and FIG. 3, Fig. 2 is a variant of transarticular fixation of the autograft with a pin;

To implement the developed method to eliminate the defect in the length of the phalanx of the toe using an autograft from the adjacent phalanx with transarticular fixation with a pin for the treatment of brachiphalangy of the toe, the following is performed.

A lateral lateral access is performed parallel to the proximal phalanx of the shortened toe in the distal direction to the level of the proposed osteotomy, the diaphysis of the proximal phalanx is exposed in layers. Further, the proximal metaepiphysis and the middle third of the diaphysis of the phalanx are isolated. A transverse osteotomy is performed, the saw blade is set parallel to the frontal plane of the finger phalanx at a distance of 0.5 cm from the articular cartilage line of the metatarsophalangeal joint from the rear to the sole of the foot. The saw blade is oriented strictly at an angle of 90 degrees to the horizontal axis of the phalanx, which helps to avoid splitting the autograft. Next, they proceed to the stage of taking the graft from the diaphysis of the proximal phalanx of the 5th toe. To do this, perform the second lateral lateral access along the outer surface parallel to the proximal phalanx 5 of the toe in the projection of the proposed osteotomy. The diaphysis of the proximal phalanx is exposed in layers. Further, at a distance of 0.5 cm from the border of the articular cartilage, an osteotomy is performed distally, orienting the saw blade perpendicular to the phalanx from the outside inwards. Next, a ruler is applied parallel to the phalanx and the distal distance necessary for the transplant recedes. The second osteotomy is performed parallel to the first, so that a cylindrical graft is obtained. The length of the graft is determined by radiographs. Radiographs are performed on a scale of 1:1, on the radiograph, the difference in the length of the diaphysis of the proximal phalanges of the fingers is determined with a ruler, the length of the graft should be sufficient so that the length of the phalanx of the finger is less than the length of the 2nd and 3rd by 0.3-0.5 cm. Further the resulting graft is placed in a saline solution (NaCl 0.9%). Next, the osteotomy of the phalanx of the adjacent finger is fixed. The distal fragment is temporarily fixed with a 1 mm Kirschner wire. To do this, the distal fragment of the phalanx is set parallel to the proximal fragment of the phalanx of the finger, the wire is passed through the proximal fragment, the entry point of the wire is located on the outer side of the base of the phalanx, the wire is oriented to the projection of the medullary canal of the distal fragment. Next, the cortical layer is reamed with a cannulated drill. The fragments are fixed by means of a cannulated, self-reaming, compression screw, which is inserted along a previously installed pin. Next, the resulting graft is installed in the area of osteotomy of the proximal phalanx of the 4th toe. To do this, the graft is placed between the distal and proximal fragments of the osteotomy. Next, the distal fragment of the proximal phalanx of the shortened finger is moved until the alignment of the proximal and distal fragments of the osteotomy and the graft is restored. Transarticular fixation of the osteotomy is performed using a 1 mm Kirschner wire. The wire is passed through the distal phalanx of the toe, orienting the wire in the direction of the medullary canal of the metatarsal bone, the entry point is on the skin of the fingertip. Next, layer-by-layer suturing of postoperative wounds is performed in the projection of the proximal phalanges.

A 12 mm long screw is used, having a full length cannulated hole with a diameter of 1.1 mm, while the proximal end of the screw has a diameter of 3.3 mm and a thread with a pitch of 0.082 mm, the distal end of the screw has a diameter of 2.5 mm and a thread with a pitch of 0.1 mm, while at the distal end of the screw there is a self-tapping sharpening on the thread, the end of the screw with a large diameter is placed in the proximal phalanx of the 5th toe, with a smaller one - in the distal fragment of the osteotomy of the proximal phalanx.

The metal fixator for osteotomy of the proximal phalanx of the 5th finger (screw) must be cannulated with double compression.

Different diameter and thread pitch in the distal and proximal parts of the screw contributes to pronounced compression, which prevents the phenomenon of delayed consolidation or non-union in the osteotomy area.

One-stage elimination of the shortening of the proximal phalanx of the finger using an autograft from the adjacent phalanx with transarticular fixation with a pin allows you to immediately restore the ratio in the parabola of the phalanges of the toes and create a visible satisfactory cosmetic effect. Thus, the length of the fingers is restored and the biomechanics in the anterior section is restored.

The distance of the osteotomy level, as well as the sizes of the segments indicated above, were obtained experimentally.

The method is illustrated with examples:

Clinical example 1:

Patient V., 25 years old, diagnosis: Brachyphalangy of the proximal phalanx of the 4th toe of the right foot. Brachymetatarsia of the 4th metatarsal of the right foot. (Fig.1)

Clinical manifestations of the disease : complaints about a cosmetic defect of the right foot, shortening of the 4th toe. There are no visible deformations of adjacent sections. According to the patient, the shortening of the 4th finger became more noticeable at the age of 12, she did not go to the doctors. The patient is concerned about the appearance of the foot, discomfort when choosing shoes.

Performed surgical correction: After preoperative preparation under spinal anesthesia, a reconstructive operation was performed on the forefoot of the right foot.

A longitudinal access was made 4 cm above the region of the 4th PFS in the region of the distal metaepiphysis, the articular capsule was opened longitudinally, a transverse osteotomy of the 4th metatarsal bone was performed, 1.5 cm away from the line of the articular cartilage of the head. The saw blade was oriented at an angle of 90 degrees to the horizontal axis of the bone. Next, an external approach was performed in the projection of the 5th metatarsophalangeal joint, blunt and sharp access was made to the metaepiphysis and diaphysis of the metatarsal bone, then a transverse osteotomy of the metatarsal bone was performed with an oscillatory saw, orienting the saw blade from the outside inwards, applying a ruler parallel to the diaphysis of the 5th metatarsal bone proximal to the sawdust, 1 cm of bone was measured for a transplant. According to the mark, a similar osteotomy was performed with the isolation of the graft. The graft is temporarily placed in saline. Temporary fixation of the head of the 5th metatarsal bone with a wire to the diaphysis, in the direction from the proximal to the distal fragment along the medullary canal, the canal was reamed along the wire, and a cannulated compressive self-reaming screw 20 mm was installed along the wire. Next, the obtained graft was placed in the area of the osteotomy of the 4th metatarsal bone, and the alignment of the obtained fragments of the osteotomy and the graft was set. After that, a temporary fixation of the osteotomy with a pin was performed, the pin was oriented to the center of the metatarsal head along the medullary canal. According to the spokes, reaming was performed through the chondral layer of the head, the graft and the proximal fragment of the osteotomy. The proximal fragment was reamed for 2 cm. A cannulated, compressing, self-tapping screw 39 mm long was installed along the needles. Next, plastic surgery was performed with a Z-shaped lengthening of the tendon of the long extensor of the 4th finger, an interrupted suture with self-absorbable sutures on the tendon.

Next, a longitudinal access of 2 cm was made along the lateral surface in the projection of the proximal phalanx of the 5th finger of the right foot, osteotomy was performed according to the technique developed by us, for which transverse osteotomy of the proximal phalanx was performed. The saw blade was oriented at an angle of 90 degrees to the horizontal axis of the bone. A transverse osteotomy of the metatarsal bone was performed with a saw, orienting the saw blade from the outside inwards, applying a ruler parallel to the diaphysis of the proximal phalanx proximal to the sawdust and measured 0.7 cm of the bone for the graft. According to the mark, a similar osteotomy was performed with the isolation of the graft. The graft is temporarily placed in saline. Temporary fixation of the free segments of the diaphysis with a needle, in the direction from the proximal to the distal fragment along the medullary canal, the canal was reamed along the needle, and a cannulated compression self-reaming screw 12 mm was installed along the needle. Then, through a 2 cm access along the lateral surface in the projection of the proximal phalanx of the 4th toe of the right foot, the resulting graft was placed in the area of the osteotomy of the proximal phalanx of the 4th toe, and the coaxiality of the obtained fragments of the osteotomy and the graft was set. After the osteotomy was fixed with a pin, the pin was oriented percutaneously through the distal phalanx into the metatarsal bone in order to fix the graft (Figure 2). At the final stage, the stability of osteosynthesis was checked, and postoperative wounds were sutured.

Clinical example 2:

Patient V., 36 years old, diagnosis: Brachyphalangia of the proximal phalanx of the 3rd toe of the right foot. Brachymetatarsia of the 3rd metatarsal of the right foot. (Figure 3)

Clinical manifestations of the disease : complaints about a cosmetic defect of the right foot, shortening of the 3rd toe. There are no visible deformations of adjacent sections. According to the patient, the shortening of the 3rd finger became more noticeable at the age of 14, she did not go to the doctors. The patient is concerned about the appearance of the foot, discomfort when choosing shoes.

Performed surgical correction: After preoperative preparation under spinal anesthesia, a reconstructive operation was performed on the forefoot of the right foot.

A longitudinal access was made 4 cm above the area of the 3rd PFS in the area of the distal metaepiphysis, the articular capsule was opened longitudinally, a transverse osteotomy of the 3rd metatarsal bone was performed, 1.5 cm away from the line of the articular cartilage of the head. The saw blade was oriented at an angle of 90 degrees to the horizontal axis of the bone. Next, an external approach was performed in the projection of the 5th metatarsophalangeal joint, blunt and sharp access was made to the metaepiphysis and diaphysis of the metatarsal bone, then a transverse osteotomy of the metatarsal bone was performed with an oscillatory saw, orienting the saw blade from the outside inwards, applying a ruler parallel to the diaphysis of the 5th metatarsal bone proximal to the sawdust, 1 cm of bone was measured for a transplant. According to the mark, a similar osteotomy was performed with the isolation of the graft. The graft is temporarily placed in saline. Temporary fixation of the head of the 5th metatarsal bone with a wire to the diaphysis, in the direction from the proximal to the distal fragment along the medullary canal, the canal was reamed along the wire, and a cannulated compressive self-reaming screw 20 mm was installed along the wire. Next, the obtained graft was placed in the area of the osteotomy of the 3rd metatarsal bone, the alignment of the obtained fragments of the osteotomy and the graft was set. After that, a temporary fixation of the osteotomy with a pin was performed, the pin was oriented to the center of the metatarsal head along the medullary canal. According to the spokes, reaming was performed through the chondral layer of the head, the graft and the proximal fragment of the osteotomy. The proximal fragment was reamed for 2 cm. A cannulated, compressing, self-tapping screw 39 mm long was installed along the needles. Next, plastic surgery was performed with a Z-shaped lengthening of the tendon of the long extensor of the 4th finger, an interrupted suture with self-absorbable sutures on the tendon.

Next, a longitudinal access of 2 cm was made along the lateral surface in the projection of the proximal phalanx of the 5th finger of the right foot, osteotomy was performed according to the technique developed by us, for which transverse osteotomy of the proximal phalanx was performed. The saw blade was oriented at an angle of 90 degrees to the horizontal axis of the bone. A transverse osteotomy of the metatarsal bone was performed with a saw, orienting the saw blade from the outside inwards, applying a ruler parallel to the diaphysis of the proximal phalanx proximal to the sawdust and measured 0.7 cm of the bone for the graft. According to the mark, a similar osteotomy was performed with the isolation of the graft. The graft is temporarily placed in saline. Temporary fixation of the free segments of the diaphysis with a needle, in the direction from the proximal to the distal fragment along the medullary canal, the canal was reamed along the needle, and a cannulated compression self-reaming screw 12 mm was installed along the needle. Then, through a 2 cm access along the lateral surface in the projection of the proximal phalanx of the 3rd toe of the right foot, the resulting graft was placed in the area of the osteotomy of the proximal phalanx of the 3rd toe, and the coaxiality of the obtained fragments of the osteotomy and the graft was set. After the osteotomy was fixed with a pin, the pin was oriented percutaneously through the distal phalanx into the metatarsal bone in order to fix the graft (Figure 2). At the final stage, the stability of osteosynthesis was checked, and postoperative wounds were sutured.

The proposed method was operated on 29 patients (32 feet). After the operation, 96.6% of patients were satisfied with the obtained cosmetic result (30 feet). All patients showed complete bone consolidation within 3 months after surgery. Complications in the form of infection, persistent pain syndrome, loss of correction were not observed. The early postoperative period in this group of patients was accompanied by a better psycho-emotional state than similar patients who were treated with external fixation devices.

EFFECT: method allows performing transarticular fixation with a pin with the possibility of removing the pin, restoring pathophysiological structures in the metatarsophalangeal joint and forefoot, which is due to the following:

- graft harvesting to eliminate shortening from the phalanx of the 5th toe. This allows not to use artificial or allograft, which makes it more likely to guarantee engraftment in the postoperative period. Such a graft has all the properties of normal bone tissue, such as homogeneity, elasticity and preservation of blood supply due to the periosteum.

- performing resection of the cylindrical part of the diaphysis of adjacent phalanges for the graft corresponds to the cylindrical section in the zone of osteotomy, which ensures the stability of the resulting connection.

- taking a graft from an adjacent phalanx allows minimizing invasiveness with one segment - the foot.

- after the osteotomy, the graft is transarticularly fixed with a pin, which allows removing the metal fixator 5 weeks after the operation. (Fig.4)

- the periosteum is preserved on the bone graft, which contributes to further blood supply to this area of the bone and is the prevention of aseptic disorders, such as delayed consolidation or non-union.

- osteotomy of the phalanx and graft harvesting does not injure the cartilage of the metatarsal head, which prevents disturbances in the PFC and the development of pseudarthrosis.

- the ability to perform early loading with the use of postoperative shoes provides early mobilization of the patient with the possibility of self-service and the possibility of an early return to daily life.

- the absence of external immobilizing structures in the postoperative period creates a favorable psycho-emotional background for the patient.

Thus, the proposed method allows to increase the efficiency of elongation of the phalanx of the toe in brachiphalangia using an autograft due to its implementation in one stage, i.e. one-stage elimination of the defect of bone shortening of the phalanx of the finger, in the end, can significantly reduce the time of treatment and rehabilitation.

Claims (1)

Method for elongation of the phalanx of the toe in brachyphalangy using an autograft, including osteotomy of the proximal phalanx, while performing a lateral lateral approach longitudinally in the proximal direction parallel to the phalanx of the finger to the level of the proposed osteotomy, exposing the site of osteotomy in layers, isolating the proximal metaepiphysis and the middle third of the diaphysis of the phalanx at the site of osteotomy , transverse osteotomy is performed, the saw blade is set parallel to the frontal plane of the phalanx at a distance of 0.5 cm from the articular cartilage line of the metatarsophalangeal joint from the rear to the sole of the foot, while the saw blade is placed at an angle of 90 ° to the horizontal axis of the metatarsal bone, then the sampling stage is performed graft from the diaphysis of the proximal phalanx of the 5th toe, a lateral lateral approach is performed parallel to the proximal phalanx of the finger in the projection of the proposed osteotomy, the diaphysis of the proximal phalanx is isolated in layers, the first osteotomy is performed proximally 0.5 cm from the border of the articular cartilage, the saw blade is oriented perpendicular to the proximal phalanx from the outside inwards , then a ruler is applied parallel to the phalanx of the finger and the distal distance necessary for the graft retreats, a second osteotomy is performed parallel to the first, so that a cylindrical graft is obtained, the resulting graft is placed in saline, NaCl 0.9%, then two segments of the diaphysis are installed parallel to each other another, temporary fixation of the osteotomy of the phalanx of the 5th finger with a Kirschner wire 1 mm is performed, for this purpose the wire is passed through the base of the proximal phalanx, the entry point of the wire is placed on the outside of the phalanx, the wire is oriented into the medullary canal to the distal edge of the phalanx, the cortical layer is reamed with a cannulated drill to the chondral layer of the distal segment of the phalanx, then the fragments are fixed by inserting a cannulated, self-reaming, compressing screw, which is inserted along the previously installed pin, then the resulting graft is placed in the area of the previously performed osteotomy of the proximal phalanx of the shortened finger, while the distal segment is moved until the alignment of the proximal, distal fragments is restored osteotomy and graft, then transarticular fixation of the osteotomy is performed using a 1 mm Kirschner wire, the wire is passed percutaneously through the distal phalanx, orienting the wire in the direction of the head of the metatarsal bone, then the needle is reamed with a cannulated drill through the distal phalanx in the direction of the medullary canal of the metatarsal bone, reamed to 6-7 cm in the medullary canal of the metatarsal bone, fixing the fragment in the area of the proposed fusion.