RU2524977C1 - Method for osteoplasty of false joints - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: reposition of fractured bone ends is followed by their longitudinal osteotomy with a twin disk saw of 5 cm in diameter to form two autografts extending one another of the width of 0.8-2 cm and the total length of 7-15 cm, one of which 2.5-5 cm long is sawed out of a smaller fractured bone, and another one 4.5-10 cm long - of a greater one. A single saw of 3.5 cm in diameter is used to extend a longitudinal osteotomy line to both sides by 2-3 cm from each of the two sides of the autografts extending one another, and the same saw is used to connect the ends of the parallel longitudinal osteotomy lines at an angle of about 45 degrees to the long axis of the autografts to form congruent pointed peripheral ends of the autografts. With a flat chisel of the width equal to or a little less than the width of the autografts both autografts are removed and interchanged with the greater one overlapping the false joint. A bone comb prepared by processing the fractured bones is tightly inserted between one of the two lateral sides of the autograft and the bone bed, and between both autografts.

EFFECT: by false joint plasty, the method enables higher clinical effectiveness in patients with non-united fractures and false joints of long extremities and reducing a length of treatment.

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Description

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

Despite the progress of surgical orthopedics, the treatment of pseudoarthrosis of the long bones of the limbs remains an urgent problem of traumatology and orthopedics. False joint - a diagnosis that excludes the hope of cure by conservative methods, the use of which in case of pseudarthrosis is ineffective. They only lengthen the already prolonged periods of treatment and exacerbate secondary disorders of the musculoskeletal system: contracture of adjacent joints, osteoporosis and trophic disorders of the injured limb. Along with stable osteosynthesis of bone fragments, the main goal of surgical treatment of the false joint is the excision of scar tissue between bone fragments, tight mutual adaptation of the fragments and activation of weakened osteogenesis.

Analogs

There are various types of surgical interventions aimed at activating osteogenesis, the most famous of which are Beck osteoperforation (Fig. 1, a), osteoplasty with an intra- and extramedullary graft according to Chaklin (Fig. 1, b) or a sliding graft according to Khakhutov (Fig. 1, c).

Criticism of analogues

The simplest of the analogues is Beck osteoperforation, however, due to its lack of effectiveness, it is practically not used at present for pseudarthrosis, since it is limited only to the drilling of sclerotic ends of bone fragments.

With the Chaklin method, intraosseous and bone marrow transplants are used, and in addition to increasing the volume and invasiveness of the operation, it is associated with the need to search for a sufficient amount of bone substance: auto- and allografts. In addition, the intramedullary graft densely clogs the bone marrow cavity, thereby inhibiting endosteal reparative osteogenesis, and the bone graft changes the contour of the bone, which complicates bone osteosynthesis.

Prototype

As a prototype method, we selected osteoplasty with a sliding autograft according to Khakhutov (Fig. 2, a, b), described in the National Guide to Traumatology / Ed. G.P. Kotelnikova, S.P. Mironova. M .: GEOTAR-Media, 2008, 808 p. S.312-314). This method of bone autoplasty consists in the fact that after exposure of the pseudoarthrosis zone and skeletonation of bone fragments for a sufficient length of autografts to be taken, a double circular electric saw cuts the bone along its length through the zone of the false joint to the desired distance. An osteotome selected along the width of the graft performs a transverse osteotomy along the edges of the sawn bone strip with the formation of two autografts of equal width but different lengths (Fig. 2, a). Then they are interchanged and the larger of the autografts overlaps the pseudoarthrosis zone (Fig. 2, b). At the same time, both autografts are fixed to the bone bed with catgut or silk ligatures or wire cerclage, carried around the bone using the Fedorov clamp or Deschan's needle. In addition, to stabilize the area of the pseudoarthrosis and bone fragments, extramedullary or extrafocal osteosynthesis is usually additionally performed.

Prototype criticism

Along with the advantages, namely the overlap of the pseudoarthrosis zone with the larger of the two autografts, the prototype method has significant disadvantages. These include the following:

- during the formation of autografts using an osteotome, the osteotomy line may not go beyond the intended range, especially with osteoporosis of bone fragments, which reduces bone strength, or with sclerotherapy of their ends, which, along with an increase in bone stiffness, is accompanied by a decrease in its elasticity and, therefore, a greater likelihood cracking. Cracking of the bone bed and (or) autografts is inevitably associated with a significant reduction in the chances of success in treating a false joint, since both mechanical and biological conditions of reparative bone regeneration are violated;

- the thickness of the circular saw blade is about 1 mm, and a slight deviation of its teeth on both sides in order to facilitate bone cutting due to a significant reduction in the friction force between the saw blade and bone makes the osteotomy line width when cutting autografts more than 1 mm. Therefore, when two parallel osteotomy bands are formed on bone fragments on both sides of the autograft, the total width of both slots between the free autografts placed in the bone bed and their bed varies in the range from 1.5 to 3 mm. Moreover, the greater the contact between autografts and their bed on one side, the wider the gap on the other;

- the expansion of the gap between the free autografts placed in the bone bed and their bed inevitably reduces their mutual adaptation and increases the risk of subsequent loss of contact between them with a slowdown in bone marrow formation, the risk of nonunion between the autografts and their bed and, accordingly, the ineffectiveness of treating a false joint;

- due to the thickening of the ends of bone fragments in case of a hypertrophic false joint, the thickness of the obtained autografts is not identical on both sides, and when the autografts are interchanged and placed in the bone bed, the outer surfaces of the autografts and the edges of their bed may not coincide, which changes the bone contour with a violation quality and stability of subsequent bone osteosynthesis (if selected);

- to fix autografts to the bone bed, you need to hold catgut or silk threads or cerclage around the bone using Fedorov’s clamp or Deschan’s needle, for which it is necessary to skeletonize it around the perimeter. This reduces vascularization and, accordingly, the regenerative potency of bone fragments;

- the presence of ligatures or cerclage in the area of the pseudoarthrosis lengthens the healing time and increases the risk of inflammatory complications.

The purpose of the invention is to increase the effectiveness of treatment of patients with pseudoarthrosis of the long tubular bones of the limbs.

SUMMARY OF THE INVENTION

A method of bone grafting of false joints is proposed, which consists in using a sliding autograft as follows. After excision of the scar tissue between the bone fragments and reposition of their ends, a longitudinal osteotomy of the bone fragments is performed with a double circular saw, 5 cm in diameter, with the formation of two mutually extending autografts with a width of 0.8-2 cm and a total length of 7-15 cm. One of these autografts, 2.5-5 cm long, are cut out from a smaller bone fragment, and another, 4.5-10 cm long, from a larger one (Fig. 3, a). Then, with a single saw, with a diameter of 3.5 cm, continue the line of longitudinal osteotomy on both sides by 2-3 cm on each of the two sides of the autografts continuing each other (Fig. 3, b). The same saw connects the ends of the parallel lines of the longitudinal osteotomy at an angle of about 45 degrees to the longitudinal axis of the autografts with the formation of congruent pointed peripheral ends of the autografts (Fig. 3, c). Using an osteotome with a width equal to or slightly less than the width of the autografts, both autografts are removed from their bed and interchanged with the overlap of the pseudoarthrosis zone with the larger one. In order to exclude the secondary displacement of the autografts and enhance their adaptation to the bone bed, bone gravel is tightly inserted between one of the two sides of the autografts and the bone bed and both autografts. The source of the latter is, firstly, closure bone plates at the ends of bone fragments, secondly, the pointed edges of the inner surface of the autografts extracted from the bone bed and, thirdly, excessive bone strata with thickening of the ends of bone fragments with hypertrophic false joint (Fig. 4a). The thickened ends of the bone fragments are tangentially modeled with an osteotome (Fig. 4, b), and the bone gravel obtained in this way is fragmented so that it can be tightly inserted into one of the two slots between the autografts and the bone bed and between both autografts. Thus, after cutting out both bone autografts (Fig. 5, a), they are removed with a chisel from the bone bed and interchanged: in place of the smaller one (1), the larger one (2) is placed so that the larger autograft (2) covers the area false joint (Fig.5, b). Due to the fact that the thickness of the circular saw blade is about 1 mm, and a slight deviation of its teeth on both sides in order to facilitate bone cutting and reduce friction between the saw blade and bone makes the osteotomy line width more than 1 mm, the total width of both slots between free autografts placed in the bone bed and their bed varies in the range from 1.5 to 3 mm. Therefore, to eliminate the secondary displacement and loss of autografts from the bone bed and to enhance mutual adaptation between the autografts and the bone bed on the one hand, bone gravel is tightly inserted into the gap between them on the other side (3) (Fig. 5, c). For the same purpose, bone gravel is also inserted into the gap between both autografts (4), thereby enhancing the contact between the pointed peripheral ends of the autografts and the peripheral end surfaces of the bone bed (Fig. 5, c). The sequence of actions is as follows: 1) the larger of the transplants (2) is placed in the bone bed; 2) by lightly tapping the hammer on the end surface of the larger of the grafts, its point is wedged into the bone bed congruent to it; 3) put the smaller of the grafts (1) in place of the larger (2) and insert the osteotome blade into the gap between them, using it as an adapter for similar tapping on the end surface of the autograft and wedging its tip into the bone bed; 4) between grafts (1 and 2) bone gravel is densely implanted with a raspator (4); 5) similarly, between bone grafts and one of the sides of the bone bed, bone gravel is densely implanted (3). Then osteosynthesis is performed (bone or extra focal) and the wound is sutured in layers.

An example of the method

As an example of the application of the proposed method for bone grafting of false joints of long bones of limbs, we give the following observation.

Patient K., born in 1985, was admitted to the orthopedic department of the Republican Orthopedic Traumatology Center (ROTC) on 6.06.2011 with a diagnosis of Hypertrophic pseudarthrosis of the middle third of the left tibia.

The patient was disturbed by pain, pathological mobility and deformation in the region of the middle third of the left lower leg with a sharp restriction of the function of the left lower limb.

From the anamnesis: in January 2009, as a result of an accident, she received an open comminuted fracture of the bones of the middle third of the left leg. She was treated at the ROTC, where the osteosynthesis of the tibia was performed using a plate with 6 screws. The fracture did not heal, and after 10 months there was a fracture of the plate with a secondary displacement of the fragments. In December 2009, the ROTC performed metal removal and extra focal osteosynthesis using the Ilizarov apparatus. After a clinical test, after 6 months, the Ilizarov apparatus was dismantled, but after 2 weeks, pathological mobility appeared. Immobilization was extended, however, a false joint of the tibia formed.

On examination, a shortening of the left lower limb by 1 cm was noted due to the shin segment, in the middle third of which there was a dense thickening, pathological mobility and palpation of tenderness. On the front surface of the leg segment there was a postoperative scar 10 cm long, not fused with the underlying tissues. On radiographs of the left tibia in 2 projections dated 05/18/11, a hypertrophic pseudoarthrosis of the middle third of the tibia was noted with a shift in width, the presence of excess bone callus, locking plates and sclerosis of the ends of bone fragments.

06/10/11, the operation was performed: Resection and bone autoplasty of the false joint, extrafocal osteosynthesis of the tibia and osteotomy of the fibula of the left tibia. A longitudinal skin incision was made along the old postoperative scar, with a convexity of the inside 1-2 cm lateral to the tibial crest, 7-8 cm long. Subcutaneous tissue, fascia and periosteum along the tibial crest were dissected throughout the wound. The periosteum and the anterior muscle group (anterior tibial muscle) are retracted outward with economical exposure of the zone of the hypertrophic false joint of the tibia with thickened and sclerotic ends of bone fragments. Bone fragments along the fracture lines are smoothed and covered with dense excess callus. With the help of raspators, an osteotome and verified, bone fragments were separated with excision of the interponing scar-cartilaginous tissues, tangential modeling of the thickened ends of bone fragments with an osteotome and restoration of patency of the medullary canal with a drill and awl. The bone gravel obtained in this case was collected in a glass with saline. From an additional external incision, a semi-closed osteotomy of the fibula was performed at the level of the border of the upper and middle third of the leg, where there was a bayonet-like deformation. Then, bone grafting was performed with a sliding autograft, for which, after the bone fragments were repaired, their longitudinal osteotomy was performed with a double circular saw, 5 cm in diameter, with the formation of two autografts extending each other, with a width of 1.5 cm and a total length of 9 cm, one of which 3 cm long, was cut from a smaller (distal) bone fragment, and another, 6 cm long, from a larger (proximal) one. Then, with a single saw, with a diameter of 3.5 cm, the lines of osteotomy are continued on both sides by 2.5 cm on each of the two sides of the autografts continuing each other. With the same saw, the ends of the parallel lines of the longitudinal osteotomy were connected at an angle of about 45 degrees to the axis of the tibial segment with the formation of congruent pointed peripheral ends of the autografts. Using an osteotome 1 cm wide, both autografts were removed from their bed and rearranged in places with the overlap of the pseudoarthrosis zone with the larger one. By lightly tapping the hammer on the end surface of the latter, the penetration of its tip into the bone bed congruent to it was achieved. Then, an osteotome blade was inserted into the gap between both autografts, using it as an adapter for tapping with a hammer on the end surface of a smaller autograft with a similar penetration of its tip into the bone bed. Bone gravel, which remained after modeling the ends of bone fragments, was tightly implanted between the two autografts with a raspator. Also, bone gravel was tightly inserted between the grafts and one of the sides of the bone bed. Then, the second stage of the operation performed extrafocal osteosynthesis of the lower leg with the Ilizarov apparatus of 4 rings, 150 mm in diameter, for which two pairs of mutually intersecting Kirchner spokes, 1.5 mm in diameter with a cross angle of about 60 degrees, were drawn through the upper and lower metaepiphyses of the tibia. The spokes are stretched and fixed in the base rings, and 2 pairs of spokes are drawn through, stretched, fixed and fixed. Osteosynthesis is stable and consistent. The wound was sutured in layers, leaving perforated tubular drainage.

On control radiographs of the middle third of the right tibia in 2 projections from 06/15/11, a satisfactory reposition of bone fragments of the tibia after bone grafting with the presence of the Ilizarov apparatus is noted. The postoperative period was uneventful. The wounds healed by primary intention. The patient was discharged for outpatient treatment at the place of residence on 06/21/11 with detailed recommendations.

On stage radiographs, 1 month, 3 and 5 months, 1 and 2 years after the operation, bone callus formation, increased optical density and remodeling with blurring of the contours of the ends of bone fragments, disappearance of the gap between them and restoration of the bone marrow canal were noted. The Ilizarov apparatus was dismantled 6 months after the operation. The function of the lower limb is fully restored. Early and long-term results of treatment are regarded by us as good.

Features of the invention, distinctive from the prototype

Distinctive features of the prototype of the proposed method of bone grafting of false joints are:

- use when taking a cortical-spongy autograft of a double circular saw with a diameter of 5 cm and a distance between its disks of 0.8-2 cm and a single circular saw with a diameter of 3.5 cm;

- after reposition of bone fragments, a longitudinal osteotomy of bone fragments is performed with a double circular saw, 5 cm in diameter, with the formation of two autografts continuing each other, and then with a single saw, with a diameter of 3.5 cm, continue the line of longitudinal osteotomy in both directions by 2-3 cm on each of the two sides of the ongoing autografts, after which the same saw connects the ends of the parallel lines of the longitudinal osteotomy at an angle of about 45 degrees to the longitudinal axis of the autografts with the formation of congruent the friction of the peripheral ends of the grafts;

- the sharpening of the peripheral ends of the autografts provide their wedging in congruent peripheral parts of the bone bed;

- after changing the autografts in places by lightly tapping the hammer on the end surface of both autografts, their point is wedged into the congruent bone bed. In this case, an osteotome blade is inserted into the gap between the grafts, the width of which is not greater than the width of the autografts, and this osteotome is used as an adapter for tapping on the end surface of the autograft;

- a bone gravel is tightly inserted between one of the two sides of the autografts and the bone bed and both autografts, the source of which is, firstly, the locking bone plates at the ends of the bone fragments, and secondly, the pointed edges of the inner surface of the autografts removed from the bone bed and thirdly, excess bone stratum ends of bone fragments with hypertrophic false joint.

The technical result (advantages over the prototype) of the method of bone grafting of false joints:

- precision accuracy of autograft grafting with the exception of cracking and osteotomy line beyond the intended range;

- minimizing the likelihood of mechanical weakening of autografts and the donor site;

- providing jamming of the pointed ends of the autografts in the bone bed congruent to them when tapping on their end surface;

- minimizing the risk of secondary displacement and “loss” of autografts from their bed;

- ensuring close contact between autografts and the bone bed, which, in addition to the mechanical stability of their mutual fixation, provides optimal biological conditions for the reparative regeneration of bone tissue and the speediest fusion of the false joint;

- the cost-effectiveness of the method of bone autoplasty with no need to search for material (bone tissue) for plastics of the false joint;

- the rational use of excess bone tissue obtained by removing the locking plates at the ends of bone fragments and the tangential excision of excess bone strata in the process of modeling the thickened ends of bone fragments with hypertrophic false joint;

- full correspondence of the outer surface of autografts and the edges of the bone bed with the exception of the violation of the bone contour, which could reduce the quality of subsequent bone osteosynthesis (if the latter is chosen);

- the lack of need for an institution for clamping Fedorov’s clamp or Deschan’s needle and, accordingly, in skeletonizing bone fragments along their entire perimeter, accompanied by a decrease in their vascularization and weakening of regenerative potencies;

- the absence of the need for ligatures or wire cerclage in the area of the false joint with the exception of the associated risk of developing inflammatory complications.

Thus, the proposed method of bone grafting can improve the treatment of patients with pseudoarthrosis of long tubular bones.

Information sources

1. Boychev B., Conforti B., Chokanov K. Operative orthopedics and traumatology. - 2nd ed., Revised. and add. - DI "Medicine and physical education", - Sofia, 1958 - 832 p. - S. 94-101.

2. Movshovich I.A. Operative orthopedics: (Manual for doctors). - 2nd ed., Revised. and additional - M.: Medicine, 1994 - 448 p. - S.31-35.

3. Brusko A.T. Biomechanical conditions for the activation of osteogenesis // Orthopedist., Injuries. and prosthetics. - 1994 - No. 2. - S.16-21.

4. Ostroverkhoe G.E., Bomash Yu.M., Lubotsky D.N. Operative surgery and topographic anatomy. - Fifth Edition, - M .: Medical Information Agency LLC, 2005 - 736 p. - S.224-225.

5. Traumatology: national leadership / Ed. G.P. Kotelnikova, S.P. Mironova. - M.: GEOTAR-Media, 2008 - 808 p. - (Series "National Guides"), s.312-314 - prototype device.

Claims (1)

The method of bone grafting of false joints, which consists in using a sliding autograft, characterized in that after reposition of the ends of the bone fragments, they perform their longitudinal osteotomy with a double circular saw, 5 cm in diameter, with the formation of two autografts extending each other, with a width of 0.8-2 cm and with a total length of 7-15 cm, one of which, 2.5-5 cm long, is cut from a smaller bone fragment, and the other, 4.5-10 cm long, is cut from a larger one, then with a single saw, 3.5 cm in diameter, continue the line of longitudinal osteotomy in both directions 2-3 cm from each of the two sides of the mutually extending autografts and the same saw connect the ends of the parallel lines of the longitudinal osteotomy at an angle of about 45 degrees to the longitudinal axis of the autografts with the formation of congruent pointed peripheral ends of the autografts, after which the osteotome is equal in width or slightly less than the width of the autografts, both autografts are removed and interchanged with the overlap of the pseudoarthrosis zone with the larger one, in addition, between one of the two sides of the auto grafts and the bone bed and between both autografts densely implant crushed stone obtained by processing bone fragments.

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