RU2816624C1 - Method of treatment of fracture of lower third of femor - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method of treating a fracture of the lower third of the femur is using an external fixation device and an intramedullary locking rod. First, an external fixation device is applied to the lower limb: two bone screws are inserted into the femur, in the upper third at the level of the lesser trochanter, the first support, made in the form of an arc, is fixed on the bone screws, enclosing the femur in front, two are inserted crosswise in the upper third of the tibia wires and two wires are carried out at the level of the diaphysis of the tibia, a half-ring is installed at the level of the tibial tuberosity, a ring is installed in the distal part of the tibia, the ring and half-ring are fixed to the wires, the ring and half-ring are connected with two threaded rods to form a second support. The first and second supports are connected by telescopic rods equipped with hinges. The first telescopic rod is installed at the medial end of the first pore, the second telescopic rod is installed at the lateral end of the first support. The hinges of the first and second telescopic rod are installed at the level of the joint space of the knee joint. The free ends of the first and second telescopic rod are installed using extension bars on the ring. The third telescopic rod is installed with one end on the medial part of the first support. The second end of the third telescopic rod is installed at the medial end of the semi-ring. An open approach to the distal epimetaphysis of the femur will be performed. Distraction is performed between the supports using telescopic rods. The hinges are loosened and distraction is carried out along the third telescopic rod. The device is fixed in the achieved position. The position of the fragments is corrected. The congruence of the articular surface of the femur is restored. The condyles are temporarily fixed with knitting needles in the reduced position. Osteosynthesis is performed with an intramedullary locking rod. The postoperative wound is sutured in layers and aseptic dressings are applied. The external fixation device is removed on the operating table.

EFFECT: invention makes it possible to reposition bone fragments when unloading the knee joint, in a given position of flexion/extension of the knee joint, with free access to the anterior surface of the knee joint for reposition and fixation of fragments.

1 cl, 4 dwg

Description

Field of technology.

The invention relates to medicine, namely to traumatology and orthopedics; it can be used in the surgical treatment of fractures of the distal femur, intra-articular and periarticular fractures of the knee joint.

State of the art.

There is a known method of surgical treatment of intra- and periarticular fractures of the knee joint, including transsegmental placement of wires at the level of the condyles of the femur or tibia, and through the diaphyses of the femur or tibia, fixing them in rings or semi-rings of the Ilizarov apparatus (1. Basic principles of transosseous compression and distraction osteosynthesis // Ilizarov G.A./ Orthopedic traumatology - 1971. - 11. - pp. 7-15. 2. Transosseous osteosynthesis for intra-articular fractures of the bones of the lower extremities // Ilizarov G. A., Shved S.I., Shigarev V.M./ Abstract of the All-Union Symposium - Kurgan - 1983. - P. 96-98)

However, the method involves closed reduction, which does not always allow for an accurate comparison of fragments, since a circular design of the device is used; the bulky design complicates X-ray control due to the large number of X-ray positive structures covering the fracture area.

For the treatment of fractures of long tubular bones, the use of internal fixation is known, and locked intramedullary (intraosseous) osteosynthesis is used. During the operation, under X-ray control, a rod is inserted into the medullary canal of the femur, which is blocked with bone screws (RU2252723). The method of closed intramedullary osteosynthesis of the femur (Guide to internal osteosynthesis, Muller M.E., Allgover M. et al., Ad Marginem, 1996, pp. 322-330), includes the application of a rod distractor, repositioning of the fracture under X-ray control, stretching and insertion intramedullary rod into the medial trochanteric region and the distal metaphysis of the femur.

Closed reduction does not allow for accurate comparison of fragments, as it is carried out under x-ray control. Monitoring the reposition of bone fragments during X-ray visualization using standard projections gives only an approximate idea of the actual position of bone fragments. When comparing fragments using an x-ray, their actual position in space may differ from what we see on an x-ray; the fragments may have unresolved displacements, which leads to disruption of the articular surface and interferes with the normal functioning of the joint.

There is a known method of osteosynthesis using plates (RU156762; M.E. Muller, M. Allgover, R. Schneider, X. Willeneger. Guide to internal osteosynthesis. - M.: Ad Marginem, 1996, p. 568-571, Fig. 13.12 e, d; 13.14). An open layer-by-layer approach to the fracture zone is performed, fragments are exposed and the articular surface is examined, the articular surface is repositioned, and temporary fixation is performed with one or more Kirschner wires. After eliminating the displacement in length, width and angle, the plate is placed along the outer surface of the femur.

However, due to open reduction, it does not always ensure restoration of joint congruence. For high-quality and accurate reposition, it is necessary to ensure the possibility of moving displaced fragments when unloading the knee joint, and various relative positions of the femur and tibia, which is technically not feasible when using the specified methods and means of reposition, since dosed flexion in the knee joint is not ensured, the action is not compensated muscles and overstretched capsular-ligamentous apparatus of the knee joint into fragments.

There is a known method for simultaneous correction and fixation of displaced fractures of the femoral condyle using the configuration of an apparatus for osteosynthesis. The arrangement of the device consists of four supports, of which the distal and proximal supports are installed on the thigh and lower leg in the middle third with two intermediate supports installed at the level of the tibial tuberosity and at the level of the middle of the patella, equipped with knitting needles and interconnected using rods (K. K. Nigmatullin. Transosseous osteosynthesis in the treatment of fractures of the knee joint // Genius of Orthopedics. - 1996. - No. 1. - P. 71-73).

The specified arrangement of the device does not allow unloading the knee joint in the flexion position, and at the same time, the structural elements obscure the view of the damaged part of the femur; there is no free access to the knee joint for surgical manipulations to restore the configuration of the articular surface of the femoral condyles.

Thus, the known methods have disadvantages.

The essence of the technical solution.

The goal is to provide treatment for a fracture of the lower third of the femur.

The technical result is the ability to reposition bone fragments when unloading the knee joint, in a given position of flexion/extension of the knee joint, having free access to the anterior surface of the knee joint for reposition and fixation of fragments.

The technical result is achieved by the fact that in the method of treating a fracture of the lower third of the femur, an external fixation device and open access to fragments of the femur are used. An external fixation device is applied to the lower limb: two bone screws are inserted into the femur, in the upper third at the level of the lesser trochanter, the first support, made in the form of an arc, is fixed on the bone screws, covering the femur in front, two wires are placed crosswise in the upper third of the tibia and two knitting needles are passed at the level of the diaphysis of the tibia, a half-ring is installed at the level of the tibial tuberosity, a ring is installed in the distal part of the tibia, the ring and half-ring are fixed to the knitting needles, the ring and half-ring are connected with two threaded rods forming a second support, the first and second supports are connected with telescopic rods equipped with hinges, wherein the first telescopic rod is installed at the medial end of the first support, the second telescopic rod is installed at the lateral end of the first support, the hinges of the first and second telescopic rod are installed at the level of the joint space of the knee joint, the free ends of the first and second telescopic rod are installed using extension bars on the ring, the third telescopic rod is installed with one end on the medial part of the support, the second end of the third telescopic rod is installed on the medial end of the semi-ring; an open approach to the distal epimetaphysis of the femur will be performed; distraction is performed between the supports along the telescopic rods, the hinges are loosened and distraction is carried out along the third telescopic rod, the device is fixed in the achieved position; carry out correction of the position of fragments, restore congruence of the articular surface of the femur; temporary fixation of the condyles with knitting needles is carried out in the reduced position; perform osteosynthesis with an intramedullary locking rod; the postoperative wound is sutured in layers and aseptic dressings are applied; the external fixation device is removed on the operating table.

The method makes it possible to freely perform reposition and fixation of bone fragments in case of a fracture of the lower third of the femur, using anterior access, on an unloaded knee joint set at a given angle of flexion of the limb, which ensures conditions for successful healing of the fracture and reduces the risk of an unsatisfactory treatment result.

The technical solution is illustrated by the following graphic materials:

Fig. 1 - radiographs of the patient’s right hip and knee joint, in frontal and lateral projections before treatment, the displacement of the fragment is visible;

Fig. 2 - radiographs of the patient’s right hip and knee joint, in frontal and lateral projections after installation of the locking rod, the displacement of the fragment was eliminated during reposition using an external fixation device;

Fig. 3 - photograph of an external fixation device mounted on the lower limb (bone model), front view, from the side of the knee joint;

Figure 4 is a photograph of an external fixation device mounted on the lower limb (bone model), side view.

On the graphic materials the numbers indicate:

1- femoral support;

2- support of the tibia;

3- femur;

4- tibia;

5- spoke;

6- bone screw;

7- threaded rod;

8- bracket;

9- ring;

10- half ring;

11 - first telescopic rod;

12- second telescopic rod;

13 - third telescopic rod;

14- hinge;

15- knee joint;

16-strut bar.

Implementation of the method.

On the operating table with the patient in the supine position under X-ray control, an external fixation device is applied to the lower limb. Two bone screws 6 are inserted into the femur 3, in the upper third at the level of the lesser trochanter of the femur 3. The support 1 is fixed on the bone screws 6, at the level of the lesser trochanter and covering the femur 3 in front. Cross-wires 5 are placed in the upper third of the tibia 4 and at the level of the diaphysis. A semi-ring 10 is installed at the level of the tibial tuberosity 4, and a ring 9 in the distal part of the tibia 4, fixing them to the spokes 5 using specifier bolts and nuts. Ring 9 and half-ring 10 are connected by threaded rods 7, spokes 5 are tensioned. Connect supports 1 and 2 with telescopic rods 11,12,13. The first telescopic rod 11 is installed at the medial end of the support 1, the hinge 14 of the first telescopic rod 11 is placed at the level of the joint space of the knee joint 15. The second end of the telescopic rod 11 is installed by means of extension strips 16 on the ring 9. The second telescopic rod 12 is installed with one end at the lateral end supports 1, hinge 14 of the second telescopic rod 11 is installed at the level of the joint space of the knee joint 15. The second end of the telescopic rod 12 is installed by means of extension bars 16 on the ring 9. The third telescopic rod 13 is installed with one end on the medial part of the support 1, the second end of the telescopic rod 13 installed at the medial end of the semiring 9.

An open approach will then be made to the distal epimetaphysis of the femur. Distraction is performed between support 1 and support 2 using telescopic rods 11,12,13. To ensure the necessary angle of flexion in the knee joint, the hinges 14 are loosened and distraction is carried out along the third telescopic rod 13, while the supports 1 and 2 rotate mutually on the hinges 14 of the telescopic rods 11 and 12. By loosening the hinges 14 and the telescopic rods 11,12,13 check the range of motion in the knee joint. They ensure full visualization of the damage zone and fix the device in the achieved position. Since the first 11 and second 12 telescopic rods are spaced to the sides of the knee joint, and the third telescopic rod 13 is located on the side of the limb, they do not block access to the joint and the lower third of the femur 3. Manipulating the position of supports 1 and 2 in doses using telescopic rods 11,12,13 and hinges 14, the surgeon can observe the condition of the fragments, their relative position when bending the knee and changing the size of the joint space, while simultaneously correcting the position of the fragments, ensuring optimal relationships, and restoring the required length. In this case, the action of the muscles and ligaments is compensated by the device; when the angle of flexion and the size of the joint space changes, the tension of the muscles and ligaments changes. A given angle of flexion in the knee joint, due to hinges 14 at the level of the joint space, makes it possible to neutralize the action of the triceps muscle on the distal fragment of the femur, facilitating reposition. Reposition of displaced bone fragments and condyles is performed and the congruence of the articular surface of the femur is restored. Having reached the optimal position of the fragments, the condyles are temporarily fixed with knitting needles in the reduced position. Next, osteosynthesis is performed using locking rods (Fig. 2), an antegrade locking rod or a retrograde locking rod is installed. The postoperative wound is sutured in layers and aseptic dressings are applied. The external fixation device is removed on the operating table.

The method is used in the surgical treatment of fractures of the distal femur, intra-articular and periarticular fractures of the knee joint.

Open reduction ensures restoration of joint congruence. For high-quality and accurate reposition, an external fixation device is mounted and used (Fig. 2; 3), which provides the ability to move displaced fragments when unloading the knee joint, and various mutual positions of the femur and tibia, since dosed flexion in the knee joint is ensured and the action of the muscles is compensated and the capsular-ligamentous apparatus of the knee joint for fragments.

When the integrity of the lower third of the femur is damaged due to displacement of bone fragments, the balance of forces and the distribution of load on the joint changes, and the biomechanics of the joint is disrupted. Moreover, muscles, ligaments and tendons prevent the fragments from moving to their original position (before the injury). The resistance of soft tissues and the ability to carry out precise reposition of fragments can be overcome by using the device, changing the length of the telescopic rods 11,12,13 and the angle in the hinges 14, flexion and extension in the knee joint are ensured and the size of the joint space is adjusted.

The device allows you to unload the knee joint in a flexion position, due to distraction or compression via telescopic rods 11,12,13, and at the same time, the structural elements do not block the view of the damaged part of the femur, access to the knee joint is open for surgical manipulations to restore the configuration of the joint surface of the femoral condyles.

Accurate alignment of bone fragments when the ends adjacent to the knee joint are damaged is critical to consolidating the fracture and restoring joint function. Inaccurate reposition of fragments, residual dislocation of fragments and associated damage to the structures of the knee joint leads to ineffective treatment, to the development of contractures or instability of the joint, which results in disability of patients.

Clinical example (Fig. 1; 2).

Clinical example of a combined surgical treatment method.

Patient X, 36 years old. He was injured as a result of an accident (hit by a car). The patient was diagnosed with: “Intra-articular fracture of the distal femur (type A3 according to the AO/ASIF classification).” X-rays of the right hip and knee joint, in frontal and lateral projections (Fig. 1): a fracture of the distal metadiaphysis of the femur is determined; on the lateral projection, a typical posterior displacement of the distal fragment of the femur is determined.

On the tenth day, the operation was performed: “Open reduction of the fracture, blocking osteosynthesis of the right femur using an external fixation device.” In the operating room, a device assembled from parts of the Ilizarov apparatus was installed. An external fixation device was applied to the lower limb: two bone screws 6 were inserted into the femur 3, in the upper third at the level of the lesser trochanter, and the first support 1, made in the shape of an arc, was fixed on the bone screws 6, covering the femur 3 in front. In the upper third of the tibia 4, two wires 5 were crossed and two wires 5 were held at the level of the diaphysis of the tibia 4, a semi-ring 10 was installed at the level of the tuberosity of the tibia 4, a ring 9 was installed in the distal part of the tibia 4, a ring 9 and a semi-ring 10 were fixed to knitting needles 5, connected the ring 9 and the semi-ring 10 with two threaded rods 7 forming the second support 2. The first 1 and second 2 supports were connected by telescopic rods 11,12,13 equipped with hinges 14, and the first telescopic rod 11 was installed at the medial end of the first support 1, the second telescopic rod 12 was installed at the lateral end of the first support 1. Hinges 14 of the first and second telescopic rod 11 and 12 were installed at the level of the joint space of the knee joint 15. The free ends of the first and second telescopic rod 11 and 12 were installed by means of extension strips 16 on ring 9. The third telescopic rod 13 was installed with one end on the medial part of support 1, the second end of the third telescopic rod 13 was installed on the medial end of the semi-ring 9. A standard anterior-outer open approach to the distal femur was performed. Distraction was performed between supports 1 and 2 along telescopic rods 11,12,13, hinges 14 were loosened and distraction was carried out along the third telescopic rod 13, and the device was fixed in the achieved position. The position of the fragments was corrected and the congruence of the articular surface of the femur was restored. The condyles were temporarily fixed with knitting needles in the reduced position. Osteosynthesis was performed with an intramedullary locking rod. If the position of the bone fragments is satisfactory and the congruence of the articular surface is restored, confirmed by X-ray, the postoperative wound was sutured layer-by-layer and aseptic dressings were applied. The external fixation device was removed on the operating table. To prevent contracture of the knee joint, the limb was not fixed with a plaster splint. After the operations, regular dressings were performed until the wound was completely healed, and therapeutic exercises of the joint were prescribed under the supervision of a physical therapy methodologist. To reduce swelling and stimulate tissue repair processes, UHF therapy of the joint and symptomatic therapy were prescribed. The patient was activated by teaching him to walk with crutches while supporting the injured limb. The full range of active movements in the knee joint was restored 1 month after surgery. Consolidation of the fracture occurred after 12 weeks. X-ray control showed that the anatomy of the femur and knee joint was restored, the articular surfaces of the knee joint were congruent. During the observation process (control visits after 3, 6, 12 and 24 months), the functional state of the affected segment of the limb and knee joint, the presence of signs of fusion in the fracture area, the width and congruence of the joint space were assessed. The length of the femur was restored and gross axial displacements were eliminated (Fig. 2).

Claims (1)

A method for treating a fracture of the lower third of the femur, in which an external fixation device and an intramedullary locking rod are used, characterized in that an external fixation device is applied to the lower limb: two bone screws are inserted into the femur, in the upper third at the level of the lesser trochanter, fixed on the bone screws, the first support, made in the form of an arc, covering the femur in front, two wires are crossed in the upper third of the tibia and two wires are passed at the level of the diaphysis of the tibia, a semi-ring is installed at the level of the tibial tuberosity, a ring is installed in the distal part of the tibia, fixed ring and half-ring to the spokes, connect the ring and half-ring with two threaded rods forming a second support, connect the first and second supports with telescopic rods equipped with hinges, the first telescopic rod is installed at the medial end of the first pore, the second telescopic rod is installed at the lateral end of the first support, the hinges of the first and the second telescopic rod is installed at the level of the joint space of the knee joint, the free ends of the first and second telescopic rod are installed by means of extension bars on the ring, the third telescopic rod is installed with one end on the medial part of the first support, the second end of the third telescopic rod is installed on the medial end of the semi-ring; an open approach to the distal epimetaphysis of the femur will be performed; distraction is performed between the supports along the telescopic rods, the hinges are loosened and distraction is carried out along the third telescopic rod, the device is fixed in the achieved position; carry out correction of the position of fragments, restore congruence of the articular surface of the femur; temporary fixation of the condyles with knitting needles is carried out in the reduced position; perform osteosynthesis with an intramedullary locking rod; the postoperative wound is sutured in layers and aseptic dressings are applied; the external fixation device is removed on the operating table.