RU2804242C1 - Method of bone autoplasty of false joints - Google Patents

Abstract

FIELD: medicine; traumatology and surgery.

SUBSTANCE: invention can be used for bone autoplasty of false joints. A circular saw is used to perform a longitudinal osteotomy of the reduced bone fragments with the formation of two, continuing each other, autografts of different lengths. An oscillating saw with a blade with a width equal to or less than the width of the sliding autografts is used to form the ends of the longitudinal osteotomy lines at an angle of 45–60 degrees to the bone surface, so that the length of the inner surface of the autografts exceeds the length of their outer surface. Both sliding autografts are reversed. At the junction of autografts with each other and the bone bed, a drill with a diameter of 4.5 mm, perpendicular to the bone surface, is used to form holes into which cylindrical autografts are inserted, blocking sliding autografts in their bed from the side of the junction of autografts with each other. Cylindrical autografts are taken from the tibia, drilling them in the frontal plane with a tubular drill with an inner diameter of 4.5 mm, and notches are made on the sides of the cylindrical autografts.

EFFECT: method provides prevention of migration and loss of contact of sliding autografts with the bone bed due to the difference in the length of the inner and outer surfaces of sliding autografts.

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Description

The invention relates to medicine, namely to methods of autologous bone grafting used in traumatology and orthopedics.

Treatment of false joints of the tubular bones of the extremities remains an urgent problem in traumatology and orthopedics. Conservative treatment of false joints is ineffective and only prolongs the already protracted treatment period. Along with stable osteosynthesis of bone fragments, the main goal of surgical treatment of a false joint is the activation of weakened reparative osteogenesis.

Analogs

There are various types of surgical interventions aimed at activating osteogenesis, the most famous of which are osteoperforation according to Beck, osteoplasty with intra- and extramedullary graft according to Chaklin or sliding autograft according to Khakhutov.

Criticism of analogues

The simplest analogue is osteoperforation according to Beck, which consists of forming several channels in the sclerotic ends of bone fragments in different directions using a wire or a thin drill. However, at present, due to lack of effectiveness, this analogue has not found widespread use.

With the Chaklin method, intraosseous and extraosseous grafts are used, and in addition to increasing the volume and traumatic nature of the operation, this method is associated with the need to find a sufficient amount of bone substance: auto- and allografts. In addition, the intramedullary graft tightly plugs the bone marrow cavity, thereby inhibiting endosteal reparative osteogenesis, and the bone graft, in addition to the need for additional fixation, changes the contour of the bone, which complicates bone osteosynthesis.

Prototype

As a prototype method, we chose osteoplasty with a sliding autograft according to Khakhutov, described in the National Guide to Traumatology (edited by G.P. Kotelnikov, S.P. Mironov, - M.: GEOTAR-Media, 2008, - 808 p. pp. 312-314). This method of bone autoplasty consists in the fact that after exposing the area of the pseudarthrosis and skeletonizing bone fragments over a length sufficient for taking autografts, a double circular saw is used to saw through the bone along its length through the zone of the pseudarthrosis to the required distance. Using an osteotome selected according to the width of the graft, a transverse osteotomy is performed along the edges of the sawed bone strip to form two autografts of equal width but different lengths. Then they are swapped, and the larger of the autografts covers the area of the pseudarthrosis. Both autografts are fixed to the bone bed with a wire cerclage or a suture thread drawn around the bone. In addition, to stabilize the area of the pseudarthrosis and bone fragments, submersible or extrafocal osteosynthesis is usually additionally performed with various metal structures.

Criticism of the prototype

Along with the advantages, namely, covering the area of the pseudarthrosis with the larger of the two autografts, the prototype method also has significant disadvantages. These include the following:

- when forming autografts using an osteotome, it is possible that the osteotomy line may go beyond the intended limits, especially with osteoporosis of bone fragments, accompanied by a decrease in bone strength, or with sclerosis of their ends, which, along with an increase in bone rigidity, is characterized by a decrease in its elasticity and, accordingly, greater likelihood of cracking. Cracking of the bone bed and (or) autografts, in turn, significantly reduces the chances of success in treating a pseudarthrosis, since both the mechanical and biological conditions for reparative bone regeneration are disrupted;

- the formation of a false joint, especially a hypotrophic one, is usually accompanied by a decrease in bone quality in the area of pseudarthrosis, expressed not only in mechanical properties (reduced density and elasticity of bone tissue with a greater likelihood of cracking), but also in biological ones - a decrease in the osteogenic potency of the sliding autografts used;

- fixation of autografts to their bed using a cerclage made of suture thread (catgut, silk, lavsan or any other) is not reliable enough, and there are frequent cases of the thread slipping to one side or the other with the loss of one or both autografts from their bed;

- wire cerclage, in which fixation is due to twisting and tight coverage of the autograft and tubular bone by the wire, is more reliable than suture material, however, achieving stable fixation of autografts to their bed is accompanied by ischemic disorders under the wire. This, in turn, is associated with the risk of necrosis and bone sequestration, and prolongation of the time of engraftment and remodeling of autografts;

- insufficiently tight contact between the free autografts laid in the bone bed and their bed and the unreliability of their fixation reduces their mutual adaptation and increases the risk of subsequent loss of contact between them with a slowdown in the formation of callus, the danger of non-union between the autografts and their bed and, accordingly, the ineffectiveness of treatment of false joint

The purpose of the invention is to increase the effectiveness of treatment of patients with false joints of the tubular bones of the extremities.

The essence of the invention

A method of autoplasty of false joints of tubular bones is proposed, which consists in the use of sliding autografts, when changing places, the larger of them covers the area of the false joint and differs from the prototype as follows (illustrated in Fig. 1 in a section in the longitudinal and cross-sectional plane). After stripping of cartilage tissue and repositioning the ends of the bone fragments (Fig. 1a), their longitudinal osteotomy is performed with a double circular saw to form two sliding autografts of different lengths that continue each other. An oscillating saw with a blade no wider than the width of the sliding autografts is used to connect the ends of the longitudinal osteotomy lines at an angle of 45-60 degrees to the bone surface, as a result of which the length of the inner surface of the sliding autografts exceeds the length of their outer surface (Fig. 1b). Both sliding autografts are swapped, covering the area of the pseudarthrosis with the larger one (Fig. 1c). In this case, the difference in the length of the inner and outer surfaces of sliding autografts serves as an additional factor for fixing their peripheral ends in the bone bed with the prevention of migration and loss of contact of sliding autografts with the bone bed. In addition to preventing the protruding edge of the bone bed from moving upward the peripheral part of the sliding autografts, this increases the contact area and the degree of mutual adaptation of the sliding autografts with their bed. Then, at the corners of the central ends of the sliding autografts and the bone bed in contact with each other, perpendicular to the surface of the bone, using a drill with a diameter of 4.5 mm, holes are drilled, with a depth of about half the diameter of the bone (Fig. 1d), intended for inserting cylindrical autografts into them in the form of dowels , with a diameter of 4.5 mm and a length of 10-20 mm. These cylindrical autografts are taken from the patient's tibia using a hollow drill. A hollow drill, with an outer diameter of 5.5 mm and an inner diameter of 4.5 mm, can be made from a 60-70 mm fragment of the straight part of a metal urethral catheter. On one or both sides of this tube (Fig. 2a), its edge is sharpened using a fine abrasive on a sharpening machine. To do this, the tube is clamped in the drill chuck and its end is evenly sharpened at an angle of 45 degrees on a running sharpening machine with the drill running (Fig. 2b). Then, on the edge of the hollow drill being manufactured, sharpened at an angle of 45 degrees, teeth are formed with a file or drill (Fig. 2c). The other end of the tube can be sharpened in the same way, and a fragment of a Kirschner wire (Fig. 3b) is used as a drift for a hollow drill (Fig. 3a).

Using a hollow drill, a cylindrical autograft is taken from the patient's tibia (Fig. 4, a, b) as follows.

A skin incision 1-2 cm long is made along the anterior surface of the patient's shin, 1-2 cm below the level of the tuberosity and 1-1.5 cm medial to the crest of the tibia. In the frontal plane, perpendicular to the axis of the bone, abut the medial cortical plate of the tibia with a thin-walled hollow drill , fixed in the drill chuck. Pliers can be used to limit the sliding of the rotating hollow drill from the bone surface and ensure its centering when starting drilling. The spread jaws of the pliers cover the hollow drill from the sides, but do not compress it - in order to avoid obstructing the rotation of the drill. Drilling begins, and as the hollow drill is immersed into the bone, its stable centering is ensured not by the jaws of the pliers, but by the edges of the bed of the cylindrical autograft. Having drilled a section of the tibia with the cutting edge of the hollow drill exiting through the lateral cortical plate into the soft tissues, at low reverse speeds of the drill, remove the drill from the hole in the tibia, disconnect the hollow drill from the drill and remove a cylindrical autograft from it, pushing it out with the end of a Kirschner wire (Fig. 3, b), playing the role of a drift. This autograft should be divided into two equal parts and filled with both holes formed for them. To increase the length of the cylindrical autograft, you can drill a canal in the frontal plane, not strictly at a right angle to the bone axis, but deviating up or down from the perpendicular (the greater the deviation and the sharper the angle, the longer the cylindrical autograft). If the length of the cylindrical autograft is not sufficient to fill both holes formed for it at the corners of the central ends of the sliding autografts and the bone bed in contact with each other (Fig. 1, d), a second cylindrical autograft can be drilled, at a distance of 7-15 mm from the bed of the previous one autograft. On the sides of the cylindrical autografts (Fig. 5, a) shallow oblique incisions can be made with a reusable scalpel or a sharp osteotome (Fig. 5b). These notches, as an element of non-removability, are intended to enhance jamming and prevent migration of cylindrical autografts (Fig. 5b) from holes formed perpendicular to the bone surface. These holes are made with a drill, 4.5 mm in diameter, at the corners of the central ends of the sliding autografts and the bone bed in contact with each other (Fig. 6a), with a depth of about half the diameter of the bone. Cylindrical autografts, 4.5 mm in diameter and 10-20 mm in length, are tightly inserted into the holes formed for them (Fig. 6b). These cylindrical autografts play the role of dowels (Fig. 6c), ensuring stability of fixation of the central ends of the sliding autografts and the bone bed connected by them.

Example of application of the method

As an example of the application of the proposed method of bone autoplasty of false joints, we present the following observation.

Patient B., 33 years old, was admitted to the traumatology department No. 2 of the Republican Center for Traumatology and Orthopedics (RCTO) in Makhachkala on November 16, 2021, with a diagnosis of: pseudarthrosis of the middle third of the right ulna and a healing fracture of the radius with the presence of metal structures (Fig. 7a). From the anamnesis: regarding a closed comminuted fracture of both bones of the middle third of the right forearm, on June 11, 2021, the patient underwent external osteosynthesis of the forearm bones with two plates and 5 screws. The ulna did not heal, and a hypotrophic false joint formed. The patient experiences pain, mobility of bone fragments, and impaired function of the right upper limb.

On November 17, 2021, the operation was performed: Removal of metal structures from the ulna, resection of the false joint, bone autoplasty and reosteosynthesis of the ulna with a bridge plate with angular stability. The operation was performed as follows. Under general anesthesia, a skin incision was made along the old postoperative scar along the posterior surface of the middle third of the right forearm. The metal structure was isolated and removed - an LCP plate with angular stability on five 3.5 mm screws. The area of the hypotrophic pseudarthrosis is exposed with separation and stripping of the cartilage tissue from the ends of the bone fragments. The patency of the bone marrow canal and the congruence of the ends of the bone fragments were restored. A longitudinal osteotomy of the reduced bone fragments was performed with a double circular saw to form two continuous autografts with a width of 1.1 cm and a total length of 8 cm, one of which, 3 cm long, was cut out from the distal bone fragment, and the other, 5 cm long. cm, from proximal. Then, using an oscillating saw with a 10 mm wide blade, the ends of the longitudinal osteotomy lines were connected at an angle of 50 degrees to the bone surface, as a result of which the length of the inner surface of the autografts exceeded the length of their outer surface. The sliding autografts were swapped with the larger of them covering the line of contact between bone fragments. In addition to preventing the protruding edge of the bone bed from moving upward the peripheral end part of the sliding autografts, this increased the area of their contact with their bed. At the corners of the central ends of the sliding autografts and the bone bed in contact with each other, holes with a depth of 7-8 mm were formed using a drill with a diameter of 4.5 mm, perpendicular to the bone surface. These holes are designed to accept cylindrical autografts, which were taken from the patient's tibia using a prefabricated hollow drill, into them in the form of dowels. The latter has an outer diameter of 5.5 mm and an inner diameter of 4.5 mm, sharpening the edge at an angle of 45 degrees (this sharpening was performed on a fine abrasive sharpening machine, securing a hollow drill in the drill chuck and uniformly sharpening its end at an angle of 45 degrees while the machine is running sharpening machine with the drill running) and teeth on the edge formed by the drill. To harvest a cylindrical autograft from the tibia, a 1.5 cm skin incision was made, 2 cm down from the tuberosity and 1 cm medial from the crest of the tibia. Subperiosteal in the frontal plane, an emphasis was placed on the medial cortical plate in the frontal plane at a right angle to the bone axis with a hollow drill clamped in a drill chuck. To limit the sliding of the rotating hollow drill from the bone surface at the beginning of drilling, pliers were used, the spread jaws of which prevented the sliding of the rotating hollow drill. During the drilling process, as the drill was immersed into the bone, its centering was no longer ensured by the jaws of the pliers, but by the edges of the bed of the cylindrical autograft. Having drilled a section of the tibia with the cutting edge of the hollow drill exiting through the lateral cortical plate into the soft tissue, the hollow drill was removed from the wound at low reverse speeds of the drill, disconnected from the drill and a cylindrical autograft, 22 mm long, was removed from it, pushing it out with the end of a transversely bent Kirschner wire . The cylindrical autograft was divided into two equal parts and oblique notches were made on their sides with a reusable scalpel - as an element of non-removability to jam and prevent their reverse migration in previously formed holes at the corners of the sliding autografts touching each other with the central ends. Both cylindrical autografts are tightly inserted into these holes with light blows of a hammer and wedged in the form of dowels, and their ends protruding above the bone surface are smoothed with a rasp. A 3.5-mm LCP plate with angular stability was then bridged over the sliding autografts, holes were drilled with a 2.7-mm drill, and six 3.5-mm screws were inserted bicortically and locked into the plate. The wound was washed with antiseptic solutions and sutured. Clinically and radiologically (Fig. 7b), reosteosynthesis is consistent. The wound has healed initially. The treatment result was assessed as good.

Features of the invention that are different from the prototype

The design features (distinctive features from the prototype) of the method of bone autoplasty of false joints are:

- after performing a longitudinal osteotomy with a double circular saw of the reduced bone fragments with the formation of two, continuation of each other, autografts of different lengths, with an oscillating saw with a blade, width equal to or less than the width of the autografts, connect the ends of the longitudinal osteotomy lines at an angle of 45-60 degrees to the bone surface , as a result of which the length of the inner surface of autografts exceeds the length of their outer surface;

- at the corners of the central ends of the sliding autografts and the bone bed in contact with each other, perpendicular to the surface of the bone, using a drill with a diameter of 4.5 mm, holes are drilled with a depth of about half the diameter of the bone, intended for inserting into them in the form of dowels cylindrical autografts with a diameter of 4.5 mm and 10-20 mm long;

- cylindrical autografts are taken from the patient’s tibia using a hollow drill;

- a hollow drill for collecting cylindrical autografts is made of a metal tube having an outer diameter of 5.5 mm and an inner diameter of 4.5 mm;

- when making a hollow drill, its edge is sharpened on a fine abrasive of a sharpening machine, for which the tube is clamped in the drill chuck and its end is evenly sharpened at an angle of 45 degrees on a working sharpening machine with the drill running, and on the edge of the hollow drill being manufactured, sharpened at an angle of 45 degrees. use a file or drill to form the teeth;

- a fragment of a Kirschner wire is used as a drift for a hollow drill;

- a cylindrical autograft is taken from the tibia 1-2 cm below the level of its tuberosity, drilling it in the frontal plane, for which it rests against the cortical plate of the tibia 1-1.5 cm medial to the crest of the tibia with a thin-walled hollow drill fixed in a drill chuck ;

- as a limiter for the sliding of the rotating hollow drill from the bone surface and to ensure its centering when drilling begins, pliers are used, the jaws of which cover the hollow drill from the sides, but do not compress it - in order to avoid interfering with the rotation of the drill. Drilling begins, and as the tubular drill is immersed into the bone, its centering is ensured not by the jaws of the pliers, but by the edges of the bed of the cylindrical autograft. Having drilled a section of the tibia with the cutting edge of the hollow drill exiting through the lateral cortical plate into the soft tissue, the drill removes it from the tibia at low reverse speeds, disconnects the hollow drill from the drill and removes the cylindrical autograft from it, pushing it out with the end of the Kirschner wire, which plays the role of a drift ;

- this autograft is divided into two equal parts and both holes formed for them are filled with them;

- to increase the length of the cylindrical autograft, you can drill a channel in the frontal plane, not strictly at a right angle to the bone axis, but deviating up or down from the perpendicular, and the greater the deviation and the sharper the angle, the longer the cylindrical autograft;

- if the length of the cylindrical autograft is not sufficient to fill both holes formed for it at the corners of the central ends of the sliding autografts and the bone bed in contact with each other, a second cylindrical autograft can be drilled, 7-15 mm away from the bed of the previous autograft;

- on the sides of both cylindrical autografts, shallow oblique cuts can be made with a reusable scalpel or a sharp osteotome - as an element of non-removability and to enhance jamming to prevent migration of cylindrical autografts in holes formed perpendicular to the bone surface;

- holes at the corners of the central ends of the sliding autografts and the bone bed touching each other are made with a drill, 4.5 mm in diameter, with a depth of about half the diameter of the bone;

- cylindrical autografts, with a diameter of 4.5 mm and a length of 10-20 mm, play the role of dowels, ensuring stability of fixation of the central ends of the sliding autografts and the bone bed connected by them, and by lightly tapping the hammer they are firmly inserted into the holes formed for them.

Technical result (advantages over the prototype) of the method of autoplasty of false joints of tubular bones:

- precision accuracy of taking sliding autografts with a double circular saw and eliminating bone cracking with the osteotomy line going beyond the intended limits using an oscillating saw to connect both lines of longitudinal osteotomy of sliding autografts;

- stability of the position of the peripheral ends of sliding autografts with the prevention of loss of contact with the bone bed due to the greater length of their internal surface over the external one due to the connection of the ends of the longitudinal osteotomy lines at an angle of 45-60 degrees to the bone surface;

- in addition to preventing the protruding edge of the bone bed from moving upward the peripheral end part of the sliding autografts, connecting the ends of the longitudinal osteotomy lines at an angle of 45-60 degrees to the bone surface increases the contact area and the degree of mutual adaptation of the sliding autografts with their bed;

- use of cylindrical autografts in the form of dowels, minimally invasively obtained through a minimal skin incision below the tuberosity and medial to the crest of the tibia, connecting the central ends of the sliding autografts with each other and with their bed;

- the reliability of the connection of the central ends of the sliding autografts with each other and with their bed is enhanced by shallow oblique notches on the sides of the cylindrical autografts to enhance wedging and prevent their migration in holes formed perpendicular to the bone surface;

- cylindrical autografts not only play the role of dowels, mechanically enhancing the reliability of the connection of sliding autografts between themselves and the bone bed, but also help optimize the biological conditions for reparative regeneration of bone tissue in the area of the pseudarthrosis, especially hypotrophic ones, accompanied by a decrease in the quantity and quality of bone. This is due to the fact that the quality of the donor site of the tibia, located outside the area of the pseudarthrosis with compromised osteogenesis, is higher;

- the cost-effectiveness of the method of bone autoplasty with the absence of the need to search for material for plastic surgery of the pseudarthrosis.

Thus, the proposed method of bone autoplasty of false joints makes it possible to increase the effectiveness of treatment of patients with false joints of long tubular bones.

Claims (1)

A method of bone autoplasty of false joints, which consists in the use of sliding bone autografts, when changing places, the larger of them covers the area of the false joint, characterized in that a longitudinal osteotomy of the reduced bone fragments is carried out with a double circular saw with the formation of two autografts of different lengths that continue each other, then, using an oscillating saw with a blade with a width equal to or less than the width of the sliding autografts, the ends of the longitudinal osteotomy lines are formed at an angle of 45-60 degrees to the bone surface, so that the length of the inner surface of the autografts exceeds the length of their outer surface, then both sliding autografts are swapped , and at the junction of the autografts with each other and the bone bed, a drill with a diameter of 4.5 mm, perpendicular to the bone surface, forms holes into which cylindrical autografts are inserted, blocking the sliding autografts in their bed from the side of the junction of the autografts with each other; In this case, cylindrical autografts are taken from the tibia by drilling them in the frontal plane with a tubular drill with an internal diameter of 4.5 mm, and notches are made on the sides of the cylindrical autografts.

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