RU2185795C2 - Method for substituting distal fur end defect - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves cutting proximal tibiofibular articulation capsule, anterior and posterior fibula head ligaments and tibiofibular membrane. Popliteal, posterior tibial muscles and musculus soleus are partially separated from the tibia surface. Tibial osteotomy is carried out. Proximal end of the femur is transferred to the femur defect. Tibiofibular membrane is cut over the 7-10 cm long path in particular cases. EFFECT: enhanced effectiveness of treatment; avoided risk of tumor development process stimulation. 2 cl

Description

 The invention relates to medicine, namely to traumatology and orthopedics, in particular to bone pathology, orthopedic oncology.

 It is known that tumors and tumor-like diseases of the musculoskeletal system, as a rule, spread along the medullary canal and are limited within one segment. (Palshin G.L. Total arthroplasty of the femur and humerus with extensive damage to their primary tumors and tumor-like diseases in adults. Abstract of diss. Doc. Medical sciences. M. - 1998, 44 pp .; Burdygin V.N., Zatsepin S.T. et al. Endoprosthetics for safe operations in patients with tumors of long tubular bones. // 6th Congress of Traumatologists and Orthopedists of Russia. Abstracts. Nizhny Novgorod. September 9-12, 1997, p. 641).

 Therefore, the most common methods for replacing defects after radical resections are: endoprosthetics, plastic with allogeneic or autogenous materials (Zatsepin S.T. Saved operations for bone tumors. - M .: Medicine, 1984, p. 288).

 Of the latter, methods of non-free bone autoplasty for replacing a bone defect with the formation of a distraction regenerate have been universally recognized (Ilizarov G.A., Ledyaev V.I. Replacement of defects of long tubular bones due to one of the fragments. // West Surgery. - 1969, 6, p. 77-84).

 With defects in the distal end of the femur, a femoral-tibial synostosis is created with lengthening of the limb by the necessary amount by osteotomy of the remaining fragment of the femur and subsequent distraction according to the techniques of bilocal combined compression-distraction and sequential distraction-compression osteosynthesis (Shevtsov V.I., Makushin V. D ., Kuftyrev ML, Gerasimov PI Osteoplastic compensation of defects of long tubular bones according to Ilizarov // Treatment of orthopedic traumatologic patients in a hospital and polyclinic by the method of transosseous osteosynthesis developed at the KNIIKOT: Abstracts of the report of the All-Union Conf. - Kurgan, 1982. Part 1, p. 175-178).

 Sometimes, to replace the defect of the femur in order to compensate for the shortening of the thigh and equalize the length of the limb, the leg is lengthened. For this, shin osteosynthesis is performed with an external fixation apparatus, osteotomy of the tibia and fibula at one or two levels, followed by lengthening of the tibia in the distal direction (Shevtsov V.I., Makushin V.D., Kuftyrev M.L. Lower bone limb defects. Kurgan 1996, p. 116, 373). However, this method is acceptable with a small amount of defect. When the size of the femoral defect is more than 5 cm, the compensatory lengthening of the lower leg will lead to deformation of the thigh, foot, and thinning of the lower leg. In addition, the most common complications, such as inflammation, delayed bone formation in the distraction zone, regenerate deformity, occur when the defect is compensated for more than 7 cm (Barabash Yu.A. Orthopedist. Rehabilitation of patients with defects of long bones of the lower extremities. Authors. Diss. To. Ph.D. Irkutsk. 1997, p. 18).

 Replacement of the defect is achieved by lengthening part of the femur after osteotomy with the formation of a distraction regenerate according to Ilizarov (Kuftyrev L.M. Ilizarov method in the rehabilitation system of patients with hip defects. // Genius of Orthopedics. 1995, 2, p. 14-17). This technique is a prototype.

 However, this method, based on the effect of tension by stretching, can lead to pathological transformation of elongated tissues due to the activation of the natural reparative potential and proliferative activity in the segment where the tumor has already occurred. The consequence of this is the high likelihood of developing a tumor recurrence in an extended segment (Shevtsov V.I., Makushin V.D., Kuftyrev M.L. Bone defects of the lower limb Kurgan, 1996, p. 71). To eliminate the danger of stimulating the tumor process by lengthening the already affected segment, we replace the resected defect by osteotomy of the tibia not affected by the tumor process and moving its proximal fragment in the cranial direction, i.e. in the defect of the femur.

 In the available literature, we did not find our proposed method for replacing a defect in the distal articular end of the femur formed after removal of the tumor, which consists in the isolated extension of only the tibia and the movement of its proximal section. We move the cranial proximal tibia to the hip defect formed after the removal of the tumor, and we carry out the extension in the segment in which the tumor did not previously develop. These points are significant distinguishing features. They ultimately provide the desired result: restoring the length of the limb and eliminating the risk of stimulation of the tumor process.

In the list of figures indicate the scheme of the method and the stages of its implementation:
Figure 1 reflects the formation of a defect of the femur after removal of the tumor.

 FIG. 2 reflects the dissection of the proximal tibial joint and ligaments of the head of the fibula.

 Figure 3 shows a dissection of the tibial membrane.

 Figure 4 shows the mobilization of the muscles of the back surface of the leg.

 Figure 5 shows the fixation of the thigh and lower leg by the Ilizarop apparatus, the place of the osteotomy and the direction of movement of the tibia.

 6 shows an isolated movement of the proximal tibia in the cranial direction to the hip defect.

 The method is carried out as follows. From the incision of the required length along the front surface in the lower third of the thigh and knee joint, we make a resection of the distal articular end of the thigh together with the tumor (Figure 1). After this, we produce a semi-closed partial mobilization of the proximal end of the tibia. To do this, in the direction from top to bottom, we cut the capsule of the proximal tibial joint, the anterior and posterior ligaments of the head of the fibula (Figure 2). The lateral fibular ligament and tendon of the biceps were crossed earlier during the resection and removal of the tumor. Then, with a raspator or chisel, also in the direction from top to bottom, we dissect the tibial membrane for 7-10 cm. In this case, dissection should be carried out by pressing the bit to the tibia, and make sure that the front edge of the immersed bit does not move anteriorly by more than 1-3 mm from the tibial membrane and did not threaten damage to the anterior tibial artery and peroneal nerve (Figure 3). Then, pressing the chisel to the posterior surface of the tibia and sliding along it, also from top to bottom, we partially separate the attachment points of the popliteal, posterior tibial, soleus muscles and leave them on the fibula (Figure 4).

 Having carried out such a semi-closed partial mobilization, after elongation, we, on the one hand, prevent the development of foot deformation by leaving the fibula together with the attached muscles intact, and, on the other hand, not skeletonizing the tibia completely, preserve its nutrition and provide conditions for the formation distraction regenerate.

 Next, we fix the thigh and lower leg with the Ilizarov apparatus. To do this, we conduct 2-4 intersecting needles through the proximal femur, through 2-3 proximal tibia through the proximal, distal metaphyses and the middle third of the tibial diaphysis. In the lower third of the leg, one of the spokes is carried through the fibula. After fixing the spokes in the supports of the Ilizarov apparatus, we produce an osteotomy of the tibia in the upper third (Figure 5). From the 7th postoperative day in the osteotomy zone, we carry out the distraction between the supports of the apparatus at a rate of 1 mm per day, performing the elongation of the tibia in the cranial direction, isolating its proximal part in the femoral defect (Figure 6).

 The isolated movement of the tibia into the hip defect is consistent with oncological principles, since it excludes the stimulation of the reparative potential and proliferative activity associated with tissue lengthening and the effect of tension by stretching, in a segment where the tumor had already developed.

 Example. Patient K., 36 years old, was admitted for treatment with a diagnosis of a defect in the distal end of the right femur 18 cm. Two years ago, a distal joint end was resected together with a giant cell tumor with subsequent endoprosthetics, which turned out to be ineffective due to inflammatory complications. In order to replace the defect, the patient underwent surgery according to our method described above: mobilization of the proximal tibia, osteotomy for lengthening, osteosynthesis of the thigh and lower leg by Ilizarov apparatus. From the 7th postoperative day, an isolation of the tibia in the hip defect was lengthened. In the process of lengthening, the femoral defect is replaced by the proximal tibia. In a subsequent patient, femoral-tibial synostosis was performed.

 Thus, we have shown the advantages of the proposed method for replacing a defect, its practical feasibility and clinical usefulness.

Claims (2)

 1. A method for replacing a defect in the distal end of the femur, including osteotomy and distraction of the excised fragment, characterized in that a capsule of the proximal tibia joint is dissected, the anterior and posterior ligaments of the head of the fibula, the tibia membrane are partially separated from the posterior surface of the tibia of the popliteal, posterior and tibial soleus muscle, osteotomy of the tibia is performed, its proximal part is moved to the defect of the femur.  2. The method according to p. 1, characterized in that the dissection of the tibial membrane is carried out for 7-10 cm

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