RU2640945C1 - Method for tibial intercondyloid eminence fracture treatment - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: diagnostic arthroscopy of the injured knee joint is performed in standard antero-lateral and antero-medial arthroscopic portals. The fragment is placed on its bed and fixed with a tibial guide, through which the K-wire is directed via proximal epimetaphysis of the tibia. An additional "central" arthroscopic portal is performed, through which a tibial guide is placed on each fragment of the split intercondylar eminence. A cylindrical drill guide is inserted into the joint and positioned at an angle of 45° on the front intercondylar eminence. A K-wire is inserted along the guide at an angle of 45° from front to back, from top to bottom diagonally to the posterior cortical layer of the tibia. Cannulated drill bit is used to drill through the channel along the entire length of the meta-epiphysis. The wire is removed together with the drill. A biodegradable fixative is introduced into the formed channel. Changing the arthroscopic portals, medially and laterally at an angle of 70°, crosswise, front to back, from the outside to the inside, wires are inserted into the cortical layers of the medial and lateral condyles, along which channels are drilled and biodegradable fixatives are introduced.EFFECT: method allows to reduce traumatism, increase the reliability of fixation.5 dwg

Description

The invention relates to medicine, namely to traumatology orthopedics, and can be used to treat fractures of the intercondylar elevation of the tibia in adult patients.

Fractures of the intercondylar elevation of the tibia are one of the most common injuries of the lower extremities in pediatric patients and usually occur between the ages of 8 and 14, however, adult patients of the category of athletes, participants in traffic accidents and who have received high-energy injuries associated with military service. A typical mechanism of such fractures is a formed linear load on the thigh in hyperextension or a fall on the knee joint in the flexion position, during which the antero-medial portion of the anterior cruciate ligament interstitially transfers the kinetic force of the object to the attachment site, tearing paratenially or with a bone fragment at the foot level print ". According to the 1959 Meyers and McKeever classification, three groups of these fractures are distinguished: without displacement, with insignificant displacement, with cranial displacement and damage to the cruciate ligament fibers, and a relatively recently introduced fourth type - multifocal fracture with displacement. In the adult group of patients, such fractures are associated with damage to other, soft tissue, structures of the knee joint, such as menisci, capsule, collateral ligaments or traumatic cartilage detachment.

A known method of treating a fracture of the intercondylar elevation of the tibia (RF patent No. 2375978, IPC АВВ 17/56, published on 12/20/2009), including reposition of the fracture and fixation of it with a knitting needle under the control of arthroscopy, while using a fragment of the intercondylar elevation, repaired by an arthroscopic probe, in a direction from top to bottom, front to back, from outside to inside, a 2-mm retaining spoke is carried out using an anterior external arthroscopic portal and it is brought out in the area of the posterior interior surface of the medial condyle of the tibia first bone, the upper end of the spokes are bent at an angle of 90 ° in the form of a hook and pull up dipping into cartilage osteochondral fragment intercondylar eminence.

The disadvantage of the method according to the patent of the Russian Federation No. 2375978 is the fixation of a fragment of a metal knitting needle, for the extraction of which, after bone fusion, additional surgical intervention will be required. In addition, the use of a single metal spoke cannot provide reliable fixation of fragments, since it does not exclude the possibility of their rotation. During the introduction, the retaining needle inevitably deviates from a given direction due to the displacement of soft tissues. As a result, the surgeon is forced to periodically rewire the needle, injuring the surrounding tissue.

There is also a method of conservative treatment of a fracture of the anterior intercondylar elevation of the tibia (RF Patent No. 2421189, IPC A61F 5/00. Publ. 06/20/2011), which includes full extension of the lower leg in the knee joint and fixation for the period of fusion, for which the lower leg is bent into to the knee joint at an angle of 30-40 °, carry it outward, anterior displacement and internal rotation to the border of elastic resistance, upon reaching full extension of the lower leg, the effect is stopped. A fixation bandage is applied until the fracture heals.

The method according to the patent of the Russian Federation No. 2421189 reduces the morbidity and postoperative complications. However, this method of treatment has a number of indisputable disadvantages, such as prolonged immobilization, arthritis of the anterior knee joint, desmogenic contractures, and associated with this long rehabilitation periods, and, as a rule, updating surgical techniques.

Closest to the proposed is osteosynthesis according to McLennan (McLennan JG The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia // J. Bone Joint Surg. [Br]. - 1982. - Vol. 64. - P . 477-480), which consists in reposition under arthroscopic control of the intercondylar elevation and fixation of the fracture with 2-3 Krishner spokes, carried out into the zone of the repaired osteochondral fragment retrograde through the condyles of the tibia, in the direction from the bottom up and front to back, crosswise relative to each other.

The negative aspects of the McLennan method include the implantation of Kirschner spokes by the “free hand” method and the inevitable repeated trauma to the provoked hyaline cartilage of the tibia and surrounding tissues. The disadvantage of this method is the need for immobilization of the knee joint for a period of 4 to 6 weeks due to the high risk of secondary displacement of the bone-cartilaginous fragment.

The objective (technical result) of the present invention is to create a minimally invasive method for the surgical treatment of a fracture of the intercondylar elevation of the tibia in adult patients, which reduces trauma while increasing the reliability of fixation of fragments.

The problem is solved in that the method of treating a fracture of the intercondylar elevation of the tibia involves reposition of the fracture under the control of arthroscopy and its fixation by holding the fixing elements into the zone of the repaired osteochondral fragment retrograde through the condyles of the tibia. According to the invention, diagnostic arthroscopy of an injured knee joint is preliminarily performed in standard antero-lateral and antero-medial arthroscopic portals. A primary reposition is performed with a diagnostic hook and endoscopic instruments, for which a fragment is placed on its bed and fixed with a stereoscopic tibial guide, along which the Kirchner needle is passed through the proximal tibial epimetaphysis. The final reposition is performed in the knee joint flexion position of 90 °, for this, a tibial guide is installed on each fragment of the split intercondylar elevation, a cylindrical drill guide is inserted into the joint and it is set at an angle of 45 ° of the graduated scale of the guide to the front intercondylar elevation, along the guide at an angle of 45 ° from front to back, from top to bottom diagonally to the posterior cortical layer of the tibia, the Kirschner needle is inserted, a canal is drilled through the needle with a drill, n metaepiphysis entire length, together with the needle is removed and a drill channel formed administered biodegradable retainer. Changing arthroscopic portals, in a similar way, medially and laterally at an angle of 70 degrees, spokes crosswise, from front to back, from outside, to enter the cortical layers of the medial and, accordingly, lateral condyles, through which channels are drilled and biodegradable fixatives are inserted. At each stage, intra-articular control, endoscopic control and fluoroscopy are performed.

The implementation of the primary and final reposition using endoscopic instruments provides clear positioning of the fragments and their reliable fixation without injuring nearby tissues. The use of biodegradable fixatives also reduces the morbidity. Due to the fact that biodegradable fixators degenerate for a long time under the influence of hydrolysis, deforming, they increase friction of the bone and implant, increasing adhesion, and when polylocal dissolving they allow the spongy bone to be replaced while maintaining the old architectonics with minimal risk of complications.

Due to the fact that biodegradable fixatives retain their shape for a long time, good stability is ensured in the first 6-12 weeks, sufficient for the final consolidation of the fracture in the correct position and the final rehabilitation. After that, the hydrolysis deforms the implant and it is annihilated with the metabolic products of the body, therefore, there is no need for an additional operation to remove the fixatives. The installation of a tibial guide on each fragment of a split intercondylar eminence allows to avoid additional fragmentation of fragments, to ensure clear positioning of the guide knitting needle, along which a cannulated drill will subsequently be inserted. As a result, the trauma of surrounding tissues at each stage of reposition is reduced. The introduction of repairing knitting needles at an angle of 45 ° and fixing elements at an angle of 70 ° allows for the variable implantation of biodegradable fixatives, taking into account the features of the fracture. Using the free-hand method, without using the tibial guide, introducing the fixing elements at given angles is a technically difficult task.

The invention is illustrated by images, where in FIG. 1, 2 presents the stages of reposition of a fragment, in FIG. 3 - installation of clamps, in FIG. 4, 5 - options for the introduction of fixatives.

The proposed method is as follows.

A standard diagnostic arthroscopy of the injured knee joint is performed in the anterolateral and anteromedial arthroscopic portals in order to determine the type of fracture. The traumatic debris, freely floating bone fragments are removed, the damage to the ligamentous apparatus (intermeniscal ligament, anterior cruciate ligament) is treated with a shaver. Diagnostic hook and endoscopic instruments perform primary reposition. The fragment is placed on its bed and fixed with a stereoscopic tibial guide, along which through the proximal epimetaphysis of the tibia a Kirschner needle is drawn with a diameter of 1-1.5 mm. The final reposition is performed in the position of flexion of the knee joint of 90 °. The tibial guide is placed on each fragment of the split intercondylar eminence, which allows you to direct the spoke and fix the fragmentary fracture in different planes. At each stage, intra-articular control is performed endoscopic control and fluoroscopy (electron-optical converter). 0.5 cm from the lower pole of the patella, an incision of 0.5 cm is performed caudally on the skin, during which the skin, fiber and capsule are dissected (“central” arthroscopic portal). A cylindrical drill guide (soft tissue protector) is inserted into the joint and set at an angle of 45 ° to the anterior intercondylar eminence. Kirschner needle 1-1.5 mm is inserted along the guide at an angle of 45 ° from front to back, from top to bottom diagonally to the posterior cortical layer of the tibia, providing reliable fixation. The needle is introduced at low speeds, preventing "hard contact" with the reponent devices. A 2.8 mm channel is drilled through the needle with a cannulated drill, the entire length of the metaepiphysis is marked, the length of the future implant is noted. The needle is removed together with the drill and an antibiotic-coated biodegradable fixative, for example, a pin, is inserted into the formed channel (taking into account the patient’s allergic history). Changing arthroscopic portals, in a similar way, medially and laterally at an angle of 70 °, spokes crosswise, from front to back, from outside, to enter the cortical layers of the medial and, accordingly, lateral condyles, through which channels are drilled and fixators are inserted. They make final lavage and rehabilitation of the joint, suture the skin, then fix the aseptic dressing. The method of fixing with three pins provides better stability of small fragments under conditions of fracture fracture, prevents secondary displacement under the action of multidirectional forces and avoids the immobilization of a plaster cast. The determination of the direction and number of pins depends on the architecture of the fracture and is estimated by two selected classifications (Meyers and McKeever 1959 and Muller M. et al., 1991 (AO / ASIF)).

Clinical example

Patient M., 25 years old, medical history No. 27271, was admitted July 6, 2015 with a diagnosis of Closed intracarticular comminuted fracture of the intercondylar elevation of the left tibia with displacement of fragments. Closed impression-comminuted fracture of the posterior edge of the lateral condyle of the left tibia (Schatzker III) with displacement of fragments. Hemarthrosis. (AO / ASIF 41-A1 IC-1 MT-1 NV-1). Injury 10 days ago. Arthroscopic surgery was performed on the knee joint with reposition of the fracture and fixation of the intercondylar elevation by biodegradable pins according to the method described above. The postoperative course is smooth, the sutures were removed on day 7. The patient was discharged for outpatient observation in an orthopedic brace of the articulated type (90 ° flexion limitation) on crutches without loading the operated leg. From the first days, the rehabilitation protocol was launched: FTL, exercise therapy of the knee joint. After 6 weeks, walking with a dosed load is allowed in the presence of a full range of motion. Examined after 12 weeks - no complaints, range of motion in the knee joint is not limited, there are no signs of instability of the knee joint.

According to this method of treatment, 10 patients aged 23 to 45 years were operated on. Consolidation in the anatomically correct position of the intercondylar fracture was obtained in each. Long-term results were studied at 12 weeks, 24 weeks, and after 1 year (MSCT, MRI of the knee joint, in one case repeated arthroscopy not associated with previous surgical intervention). Satisfaction with the results of treatment on the part of all operated persons, low traumatism, the absence of strict immobilization and early functional rehabilitation allow us to consider this method successful and often reproducible, with minimal expenditure of resources. The invention allowed to treat adult patients, reducing the period of disability and avoiding aesthetic problems.

The considered method can be recommended in clinical practice.

Claims (1)

A method for treating a fracture of the intercondylar elevation of the tibia, including reposition of the fracture under the control of arthroscopy and its fixation by holding the fixing elements into the area of the repaired osteochondral fragment retrograde through the condyles of the tibia, characterized in that they perform preliminary diagnostic arthroscopy of the injured knee joint in standard antero-later -medial arthroscopic portals, diagnostic hook and endoscopic instrumentation primary reposition is performed, for which a fragment is placed on its bed and fixed with a tibial guide, along which the Kirschner needle is passed through the proximal tibia epimetaphysis, the final reposition is performed in the knee flexion position of 90 °, for this an additional “central” arthroscopic portal is performed, through which a tibial guide is mounted on each fragment of the split intercondylar eminence, a cylindrical drill guide is inserted into the joint and placed under scrap 45 ° to the anterior intercondylar eminence, along the guide at an angle of 45 ° from front to back, from top to bottom diagonally to the posterior cortical layer of the tibia, the Kirschner needle is inserted, a canal is drilled through the needle with a drill, the entire length of the metaepiphysis, the needle is removed together with the drill and into the formed channel is injected with a biodegradable fixator, changing arthroscopic portals, medially and laterally at an angle of 70 °, crosswise, from front to back, from the outside, knitting needles are introduced, reaching the cortical layers of the medial and corresponding enno lateral condyles, which channels are drilled and are administered biodegradable retainers at each stage produce intraarticular control, monitoring and endoscopic fluoroscopy.

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