RU2240742C2 - Method for closed osteosynthesis of trochanterian femoral fractures - Google Patents

Abstract

FIELD: medicine, traumatology, orthopedics.

SUBSTANCE: the method deals with closed reposition of fragments followed by fixing with a rod being curved by its arch, applied in medullary canal through perforated opening made at femoral surface under acute angle to bone's surface towards femoral fracture site after resecting soft tissues against the crossing site of two lines coming from anterior spine up to internal femoral condyle and from the middle of Poupart's ligament up to internal patellar edge at anterior-internal femoral surface. For fixation one should choose a flexible rod the curvature of which is 15-20 mm less than that of a line coming through the middle of caput femoris, femoral cervix and medullary canal being simultaneously the conjugation line of cervico-diaphysial angle sides.

EFFECT: increased fixation rigidity of fragments.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for the treatment of patients with trochanteric femoral fractures.

Fractures of the trochanteric region are the most common injuries in the elderly and senile. According to literature, they make up from 2 to 13.5% among other skeleton injuries; 17-30% of all fractures of the femur and more than half of its injuries in the proximal part (51-66%) [1, 2, 5]. As with other injuries of the musculoskeletal system, there are conservative and surgical methods of treatment [4].

Conservative treatment in elderly patients, most of whom suffer from concomitant somatic diseases (92%), leads to exacerbation of diseases and in 20-40% of cases to death. Thus, conservative treatment in this group of patients is often not applicable [10].

The so-called functional treatment method does not set itself the task of fully treating fractures and is used in patients who obviously will not undergo severe osteosynthesis surgery [4, 5, 11].

Surgical treatment enables early mobilization of the patient, prevents the development of hypostatic complications and creates the conditions for the fusion of fragments in the correct position. But the operation is associated with a risk to the life of the patient, and the degree of risk is directly proportional to the invasiveness of the intervention. Therefore, osteosynthesis should be less traumatic and allow sufficiently firmly fix fragments [5, 6].

The most common method of surgical treatment of trochanteric hip fractures to date is osteosynthesis with a 3-lobed nail with a diaphyseal pad or neck-diaphyseal plate [8, 13]. When using these structures, it is possible to carry out strong fixation of fragments and provide functional management in the postoperative period. But the operation is traumatic, because it requires wide access, is accompanied by significant blood loss, the probability of purulent complications is high.

In order to reduce the invasiveness of the operation, multi-osteosynthesis methods are used, when various screws and knitting needles are used to fix the fragments [14]. A significant drawback of these techniques that limit their use is that they are applicable in the presence of a cortical site in the area of the trochanter of the femur with a thickness of at least 1.5 cm. Fractures and the migration of these fixators are frequent.

Close to the proposed method of osteosynthesis is the fixation of fragments according to Ender by flexible titanium rods [5, 7, 15], introduced through the inner condyle of the thigh. This method of osteosynthesis involves the use of complex, expensive x-ray television equipment with an optical converter, in addition, the migration of the rods and, as a result, the possibility of purulent complications are not ruled out.

Closest to the proposed method is osteosynthesis with an arcuate nail according to Lecius [16] (a grooved rod with a trefoil profile and a cross-sectional diameter of 8, 9, 10 mm, having a curvature with a radius of 120 mm and three standard sizes in length - 160, 175, 190 mm) . Pre-reposition of fragments on the orthopedic table. Access to the bone with this method of osteosynthesis involves an incision of soft tissues along the anterior surface of the thigh at the border of its middle and upper third, after which a perforation hole is drilled into the bone marrow canal at an acute angle to the bone surface in the direction of the fracture site. The disadvantages of the method include its invasiveness due to the need for wide access to the bone, the formation of a large perforation hole in the bone. Quite often (in 6% of cases) there is a migration of the rod with a divergence of fragments, to prevent which the use of additional devices is necessary. Fractures of the femur at the site of insertion of the rod are observed [9, 12].

The claimed invention solves the problem of creating a method for osteosynthesis of a trochanteric femoral fracture less traumatic and simple to perform.

The technical result when using the claimed invention is to reduce the morbidity and simplification of the method.

This technical result is achieved by the fact that with closed osteosynthesis of trochanteric fractures of the femur, which includes a closed reposition of fragments with subsequent fixation by a rod curved along the arc, carried out in the bone marrow canal through a perforation hole made on the thigh surface at an acute angle to the bone surface along towards the fracture site on the thigh after a soft tissue incision from the point of intersection of two lines drawn from the anterior superior spine to the inner condyle of the thigh and from the middle of the pupar of the ligament to the inner edge of the patella on the front-inner surface of the thigh, and for fixation, choose an elastic rod, the curvature of which is 15-20 mm less than the radius of curvature of the line drawn through the middle of the femoral head, neck of the femur and the medullary canal, which is at the same time, the line connecting the sides of the cervical-diaphyseal angle.

The inventive method for the osteosynthesis of trochanteric femoral fractures is illustrated by the drawing, where 1 is the rod with the tip 6, 2 is the fracture line, 3 is the cortical wall of the femoral diaphysis, 4 is the bone marrow canal, 5 is the femoral head, 7 is the junction line between the cervical diaphyseal angle and conducted through the middle of the femoral head, femoral neck and marrow canal.

To implement the method, radiographs of the contralateral region of the intact joint are performed. A fixing rod is prepared, for which a line through the middle of the femoral head, neck of the femur and bone marrow canal is drawn on the roentgenogram of the intact limb, which is also the conjugation line of the sides of the cervical-diaphyseal angle, and its radius of curvature is measured at the interface. After that, the rod is bent for fixation so that its radius of curvature is 15-20 mm less than the radius of curvature of the above line.

After a closed reposition of fragments on the orthopedic table, under spinal or local anesthesia in combination with neuroleptoanalgesia in the supine position, the site of insertion of the rod is marked. The starting point of the soft tissue incision and the perforation hole lies at the intersection of two lines: from the anterior superior spine to the inner condyle of the thigh and from the middle of the pupartic ligament to the inner edge of the patella. The skin on the front-inner thigh surface is dissected with a scalpel from this point, the length of the incision is 1-1.5 cm. A hollow conductor is inserted into the bone through soft tissues until it stops, under the protection of which, with the help of an electric drill, a perforated hole is formed in the cortical femoral plate using a drill with a diameter of 5 mm bones at an angle of 60 degrees. In this case, the femoral artery is protected from intraoperative trauma by the medial broad muscle of the thigh. The conductor is removed. Into the perforated hole in the proximal direction, taking into account the aneurysia of the neck, the pre-prepared rod 1 is inserted into the opposite cortical plate (3) until it stops, the further advancement of which is carried out by short dosed hammer blows. Assessment of the depth of immersion of the rod into the bone is carried out by comparing it with the same rod applied to the thigh from the outside along the front surface. The rod is carried out along the bone marrow canal 4. The moment the rod enters the neck of the femur is felt by a sense of resistance to hammer blows and a decrease in the speed of advancement of the rod itself. At this stage, control radiographs of the proximal femur are performed in two (direct and axial) projections. With a satisfactory reduction of fragments and the correct location of the latch 1, the latter is achieved in the head 5. The wound is sutured, drained with a rubber strip. In the postoperative period, external immobilization of the limbs is not used. Movements in the joints begin to produce from the day after surgery. On day 3-5, the patient is allowed to walk on crutches, without relying on the operated limb. For a period of 6 weeks, a dosed load is allowed, a full load on the limb becomes possible 3 months after the operation. Removal of the rod is carried out 4-6 months after surgery. Due to the elasticity, a rod with a smaller radius is deformed and blocked in the bone marrow cavity, which increases its strength and prevents its migration in the postoperative period.

Example 1

Antonova Aleksandra Alekseevna, born 1932, trauma on the street on November 18, 2000, accidentally slipping, fell on her left side, was admitted to the trauma unit on January 3, 2001, case history No. 11511. Diagnosis: Closed transverse fracture of the right thigh with displacement of fragments along the length, width and at an angle (drawing). Concomitant diagnosis: Hypertension, chronic pyelonephritis, vascular atherosclerosis, dyscirculatory encephalopathy. On November 23, 2000, after examination and preliminary preparation, osteosynthesis was performed with a curved shaft under epidural anesthesia using the method described above. The operation lasted 45 minutes, with almost no blood loss. From the second day, the patient began to sit down in bed, hanging her legs from the bed. From the third day, she began to exercise therapy, to develop movements in the knee and hip joints of the right lower limb. The postoperative course is smooth, the wound healed by primary intention. Antibiotic therapy was not used, dressings were performed every other day. The sutures were removed on December 1, 2000. She was discharged for outpatient follow-up on December 2, 2000. In the fourth week after the operation, she started walking on crutches with a light load on the operated leg, and by the age of two months she was already walking with a full load. 04/10/2001, the rod was removed during repeated hospitalization in a hospital, the fracture was healed, a good restoration of limb functions was noted. By the time the rod was removed, the patient was free to move around the room without crutches.

Example 2

Balyasova Antonina Ivanovna, b. 1915 (85 years old), April 8, 2001, the house fell on her left side, was admitted to the trauma unit on April 8, 2001, delivered by ambulance, medical history No. 8168. Diagnosis: Closed transverse fracture of the left thigh without displacement of fragments. Concomitant diagnosis: coronary artery disease, extrasystolic arrhythmia, atherosclerosis of the aortic vessels, cerebral vessels, symptomatic hypertension, degree 2 discirculatory encephalopathy. April 9, 2001, after a preliminary examination under local anesthesia (0.25% novocaine solution 200.0 ml inside the left half of the pelvis, 0.5% -80.0 ml novocaine solution at the fracture site) and neuroleptoanalgesia performed closed osteosynthesis with a curved rod (drawing) according to the above method for 40 minutes with a minimum, up to 10, 0 ml of blood loss. From the second day, the patient began to sit in bed hanging her legs from the bed. From the third day, I began to exercise therapy-to the development of movements in the knee and hip joints of the left lower limb. The postoperative course is smooth, the wound healed by primary intention. Antibiotic therapy was also not used. Sutures were removed on April 19, 2001. Discharged for outpatient follow-up care on April 21, 2001. At the sixth week after the operation, she began to walk on crutches with a small load on the operated leg, and by the age of three months she walked with a full load. 09/20/2001, the rod was removed in the trauma hospital. The fracture is fused (drawing), the limb function in full, moves with a cane.

Using the proposed method of osteosynthesis, from January 2000 to December 2001, 148 patients were treated with good anatomical and functional results.

Sources of information

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2. Dorofeev Yu.N. Comparative evaluation of various methods of treatment of transverse-subtrochanteric hip fractures: Diss. Cand. honey. Sciences, Tyumen, 1996.

3. Kutushev F.Kh. et al. Treatment of transverse femoral fractures // Bulletin of Surgery. T.130, 1983. - No. 5. - S.90-94.

4. Lirtsman V.M. et al. Comparative evaluation and modern views on the treatment of trochanteric femoral fractures in the elderly and old people // Traumatology, orthopedics. 1990. - No. 2. - S. 42-45.

5. Malygina M.A. Treatment of trochanteric femoral fractures in elderly and senile patients with an elastic nail: Diss. Cand. honey. Sciences, M., 1991.

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Claims (1)

The method of closed osteosynthesis of trochanteric femoral fractures, including a closed reposition of fragments with their subsequent fixation by a curved rod, selected in accordance with an x-ray, carried out in the bone marrow canal through a perforation made on the surface of the thigh at an acute angle to the bone surface in the direction of the fracture site on the thigh after the soft tissue incision, characterized in that the soft tissue incision and the hole are performed from the intersection of two lines drawn from the front to of the ankle to the inner condyle of the thigh and from the middle of the pupartic ligament to the inner edge of the patella on the front-inner surface of the thighs, and for fixation, choose an elastic rod whose curvature is 15-20 mm less than the radius of curvature of the line drawn through the middle of the femoral head, the femoral neck and the bone marrow canal, which is simultaneously the line of conjugation of the sides of the cervical-diaphyseal angle.