RU2801711C1 - Method of reconstructing the bones of the orbit - Google Patents

Abstract

FIELD: medicine; ophthalmic surgery; maxillofacial surgery.

SUBSTANCE: invention can be used for reconstruction of orbital bones. An implant made of titanium mesh consisting of two plates is used. Each plate has a retainer located at an angle to the surface of the implant, designed for attachment to the periosteum of the corresponding bone of the orbit, depending on the location of the fracture, and the following marking: R — right, L — left, A — front edge, P — rear edge for location relative to the defect. One of the plates is provided with a guide protrusion with a groove for aligning the plates and preventing their displacement relative to each other, oriented parallel to the implant surface. Surgical access is performed with a length of 1/2 of the size of the implant in a fastened form, parts of the implant are inserted one by one in accordance with the marking applied to them, and they are positioned according to the defect. Then the parts of the implant are fastened together using a guide protrusion and fixed to the periosteum of the corresponding bone of the orbit, depending on the location of the fracture, using microscrews.

EFFECT: method allows to reduce the invasiveness of the intervention due to the possibility of performing the operation through an incision significantly smaller than the implant, and introducing an implant larger than the entrance to the orbit, as well as to provide the possibility of the most complete closure of the bone defect even with its irregular shape, which contributes to the optimal restoration of the anatomical shape orbital area and eye function, as well as accelerating the rehabilitation of patients.

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Description

The invention relates to medicine, namely to ophthalmic surgery and maxillofacial surgery, and can be used in operations to restore the walls of the orbit.

Injuries of the zygomatic-orbital complex are characterized by the destruction of the walls of the maxillary sinus, the lower and outer walls of the orbit, the zygomatic bone, combined with damage to the eyeball, its auxiliary apparatus and soft tissues of the face (Nikolaenko V.P. On the variety of injuries of the lower orbital wall. Ophthalmological sheets. 2012; 5 (1): 98-109).

In the treatment of traumatic injuries of the orbit, accurate volumetric and anatomical reconstruction is necessary in order to restore the normal functions of the organ of vision, on the one hand, and to prevent the development of such late complications as eno- and hypophthalmos, on the other.

The main stages in the complex of therapeutic measures in patients with injuries to the bones of the face, bottom and walls of the orbit include osteotomy, reposition and stable fixation of bone fragments in the correct anatomical position.

The final stage in patients with post-traumatic deformities of the zygomatic-orbital region is plastic surgery of the orbit with various materials. The goal of plastic surgery is to restore the anatomical shape of the zygomatic-orbital region and the function of the eyes, to eliminate the deformation of the zygomatic, infraorbital regions and the bottom of the orbit with a single implant to raise the eyeball up to the anatomical and physiological level (Aleksandrov N.M., Arzhantsev P.Z., Vikhriev B.S. etc. Injuries of the maxillofacial region // M.: Medicine, 1986).

One of the materials used in the reconstruction of the orbit is an allogeneic graft.

A known method of reconstructing the walls of the orbit in case of a fracture (patent RU No. 2286110), according to which the reposition of bone fragments is performed through the working hole under endoscopic control using an auxiliary hole, the graft is fixed on one side to the anterior section of the lower wall of the orbit, and on the other side to the bone section of the retrobulbar parts of the eyeball. Bone fragments of the orbital wall are sutured to the graft along the entire length. EFFECT: method makes it possible to form the correct ratio between the bone fragments of the periorbital fiber and the oculomotor muscle, reduce blood supply disturbances in the operation area, and restore the normal movement of the eyeball.

However, the method is technically complicated, requires the use of expensive equipment, in addition, the use of an endoscope complicates access to damaged fragments, and also increases the risk of damage to the periocular structures and the development of complications from the upper sinus.

Currently, titanium or titanium alloys are often used in facial reconstructive surgery. Titanium has biological inertness, corrosion resistance, non-toxicity, high mechanical strength, ductility, non-magnetism, low specific gravity

There is a known method of restoring the lower wall of the orbit and the infraorbital region after injury (patent RU No. 2486872), in which a support is modeled from a plate of porous titanium nickelide 0.8-1.0 cm wide based on the medial and lateral edges of the bone defect. The titanium nickelide mesh implant is modeled in accordance with the parameters of the bone defect and it is inserted through the subciliary access supported by the distal edge on the previously modeled porous titanium nickelide implant. Installed in the correct anatomical position, bent over the lower orbital margin, and then straightened over the periosteum of the anterior wall of the maxillary sinus. The method allows to provide adequate anatomical restoration of the lower wall of the orbit.

A known method for the treatment of fractures, deformities and defects of the lower wall of the orbit (patent RU No. 2526878), which eliminates defects in the lower wall of the orbit by introducing a curved L-shaped titanium plate with a silicone block in the short part into the defect area. The plate is fixed by the long part to the anterior wall of the maxillary sinus or by the long part to the alveolar process of the upper jaw.

As the closest analogue, a method for prosthetics of the walls of the orbit using implants made of porous titanium nickelide (RU No. 2297817) was adopted. The essence of the method is as follows: the defect of the orbital wall is replaced with a permeable implant made of porous titanium nickelide, modeled in accordance with the configuration of the bone defect based on the patient's computed tomography data. According to the known method, an implant for modeling uses a plate of porous titanium nickelide. The implant is placed on the edges of the bone defect, if possible, subperiosteally, replenishing the lost fragment of the orbital wall.

However, all of these methods have the following disadvantages. Insertion of an implant modeled according to the size of a bone defect requires an extended incision during the formation of an intra-sinus access corresponding to the size of the implant, as well as a large number of manipulations with the soft tissues of the orbit during installation and fixation of the implant, which increases the trauma of the intervention, increases the risk of complications and complications. prolongs the operation time.

The present invention solves the problem of developing a new method for the surgical treatment of an injury to the middle zone of the face, which allows the installation and stable fixation of the implant with a decrease in trauma to the tissues of the orbit and the implementation of a minimal incision for access to the bone defect.

Usually, the size of the implant exceeds the size of the entrance to the orbit, and even if the implant design consists of several parts, these parts correspond to the size of the bone defect and require an extended tissue incision corresponding to the size of the implant, as well as a large number of manipulations with the soft tissues of the orbit during installation and fixation of the implant which increases the invasiveness of the intervention, increases the risk of complications, lengthens the time of the operation and does not always allow the patient to be satisfied with the aesthetic result of the operation due to the large length of the scar.

The task can be solved using a composite titanium mesh implant obtained on the basis of computed tomography data with 3D reconstruction and modeling of a bone defect, depending on the architectonics of the middle zone of the face, on the basis of which the shape and size of the implant are determined. An implant template is modeled, which is divided into two approximately identical components (right and left) 1 and 2 (see Fig. 1, 2) in the form of plates, based on the individual characteristics of the patient's bone defect. The simulated implant is made by additive manufacturing. Each implant plate has a retainer (3) and (4) located at an angle to the implant surface, designed for attachment to the periosteum of the corresponding orbital bone, depending on the location of the fracture, and marking - R - right, L - left, A - front edge, P is the rear edge for location relative to the defect. One of the plates is provided with a guide protrusion (5) with a groove (6) for aligning the plates and preventing their displacement relative to each other, oriented parallel to the implant surface.

The essence of the invention lies in the fact that when performing an operation to reconstruct the walls of the orbit using a composite implant made of mesh titanium, made on the basis of the individual characteristics of the patient's bone defect, a surgical approach is performed, which is 1/2 or less than the size of the implant in a bonded form, parts of the implant in accordance with the markings applied to them (R - right, L - left, A - front edge, P - back edge) and position them according to the defect. They are fastened together with the help of a guide protrusion and fixed to the periosteum of the corresponding bone of the orbit, depending on the location of the fracture, with the help of microscrews.

The technical result from the implementation of the invention is as follows:

- the invasiveness of the intervention is reduced due to the possibility of performing the operation through an incision that is significantly smaller than the size of the implant and the introduction of an implant that is larger than the entrance to the orbit, and less invasiveness of manipulations with the soft tissues of the orbit, primarily with the eyeball, is achieved;

- provides the possibility of the most complete closure of the bone defect, even with its irregular shape, which contributes to the optimal restoration of the anatomical shape of the orbital region and eye function, and also accelerates the rehabilitation of patients.

The method is carried out as follows. The operation is performed under combined anesthesia. An incision is made in the skin and underlying tissues in accordance with the size of the implant component in the projection of the orbital margin (or conjunctiva - with transconjunctival access), which is 1/2 or less than the size of the implant in the bonded form. With the help of a raspator and a spatula, the periosteum is separated, the edges of the bone defect are isolated so that it is well visualized, bone fragments are removed. The prolapsed soft tissues are adjusted, hemostasis is performed using a diathermocoagulator, if necessary, by applying vascular ligatures. One part of the implant is introduced, focusing on the applied marking (R - right, L - left, A - front edge, P - rear edge) and position it according to the defect. Further, guided by the same principles, the second part of the implant is inserted. They are fastened together using a guide protrusion and fixed to the periosteum of the corresponding orbital bone (depending on the location of the fracture) using microscrews. The surgical wound is sutured in layers, locally, according to indications, an antibiotic is introduced.

The invention is illustrated by the following clinical example.

Patient K., born in 1971 She applied for a consultation at the Federal State Institution "NMIC" IRTC "Eye Microsurgery" named after A.I. acad. S.N. Fedorov 04.02.2022.

Anamnesis: According to the words, on 11/30/2021, as a result of a criminal attack, she received a gunshot wound to her left eye. PHO on the same day and removal of the remains of a destroyed eye in Kaliningrad. 12/07/2021 the second operation in the same place - OS - plastic surgery of the lower fornix with permanent blepharorrhaphy.

Complaints: unsatisfactory appearance of the left orbit, absence of the left eye, difficulty in prosthetics.

Status oculorum: OS anophthalmos, eyelids sewn on cylindrical plastic spacers (since 12/07/2021). The stitches were removed, the eyelids remained unfused. There is a double-walled glass prosthesis with rounded edges in the cavity, the lower vault is slightly reduced, rigid, the cavity with a deep upper vault, the stump is empty. The position of the prosthesis is quite stable. Barely noticeable movements in the cult are determined. The eyelids are motionless, the upper eyelid is completely lowered. According to the results of CT scan dated 02/02/2022: comminuted fractures of the upper, inner and lower walls of the left orbit, the volume of the orbit is increased due to the uniform displacement of the lower and inner walls. Fragments of bones of the upper wall are displaced into the orbit by 2-3 mm. Anophthalmos, EOM in the usual places, in the posterior third in the lower-inner sector, coarse scars of soft tissues.

Diagnosis: OD: Myopia stat. weak and moderate degree; OS: Consequences of an eye injury in the periorbital region, consequences of an injury to the right orbit and the right eye, traumatic orbital deformity, anophthalmic syndrome, cicatricial deformity of the conjunctival cavity. Surgical treatment recommended

On June 14, 2022, the orbit was reconstructed at OS using the proposed implant - a composite individual titanium plate. A surgical access was made with a length of 1/2 of the size of the implant in a bonded form. The edge of the orbit is highlighted. The scar tissues are bluntly and sharply separated from the inferior and medial walls of the orbit. Rough scars were dissected in the layer of the lower wall of the orbit. The maxillary sinus is exposed. An individual composite titanium implant is placed on the medial and inferior walls of the orbit, fixed with screws along the anterior edge. The wound was sutured in layers. A prosthesis is placed in the cavity. Temporary blepharoplasty. Bandage applied.

Inspection in a week 06/21/22.

The position of the implant is correct. Swelling and subcutaneous hemorrhages persist in the eyelid area, palpation is slightly painful. The seams are clean. No complaints, the condition is satisfactory.

Claims (1)

A method for reconstruction of orbital bones, including replacement of a bone defect with an implant modeled in accordance with the configuration of the bone defect based on computed tomography data of the patient, characterized in that an implant made of mesh titanium is used, consisting of two plates, each plate having a retainer located at an angle to implant surface, designed for attachment to the periosteum of the corresponding orbital bone, depending on the location of the fracture, and marking - R - right, L - left, A - front edge, P - rear edge for location relative to the defect, and one of the plates is equipped with a guide protrusion with a groove for aligning the plates and preventing their displacement relative to each other, oriented parallel to the implant surface, while the surgical access is performed with a length of 1/2 of the size of the implant in a fastened form, the parts of the implant are inserted one by one in accordance with the marking applied to them, they are positioned according to the defect, then the parts of the implant are fastened together using a guide protrusion and fixed to the periosteum of the corresponding bone of the orbit, depending on the location of the fracture, using microscrews.

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