RU2654593C1 - Surgical access to the lateral curve of the large-curved bone fassioplastic with osteotomy of zherdi tubercule - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the field of medicine, namely to surgery, in particular to traumatology and orthopedics, and is intended for use in the treatment of fractures in the region of the lateral condyle of the tibia. In surgical access, an incision is made on the lateral surface of the knee joint area from the lateral epicondyle of the femur distally towards the tuberosity of the tibia, not reaching the last 2 cm. Next, the cutaneous subcutaneous flap is pulled out sharply, which is retracted posteriorly, fascia and the fascia of Zherdi, which extends through the fascia. Further, an L-shaped incision of the intrinsic fascia is made, which begins 3 cm proximal to the joint gap from the level of the lateral collateral ligament. Incision is conducted parallel to the joint slit to the patellar ligament, after which it is rotated perpendicular and leads in the distal direction to the level of tuberosity of the tibia. Produced fascial flap is exfoliated in an acute way from the underlying joint capsule, then performing an osteotomy of the Zherdi hillock, which greatly facilitates the separation of the flap. Formed flap is removed in the dorsal direction. Conducting a substitutive arthrotomy of the knee joint, performing a fracture reposition and osteoplasty. Final fixation is carried out by the support plate. After osteosynthesis of the fracture in its correct position, the continuity of the fascial-ligamentous apparatus of the knee joint is restored by applying a single encircling continuous stitch to the fascial flap first in the proximal part (to prevent tissue deficit), then in the distal, an active drainage is installed under the fascia. Skin-subcutaneous flap is sutured with separate nodular sutures.

EFFECT: method makes it possible to improve the conditions for surgery on the knee joint, to create a sufficiently spacious and safe access to the external condyle of the knee joint, which makes it possible to cover the metal fixator with a deep fascia of the shin, while not breaking the fascial-ligamentous apparatus of the knee joint in its lateral section.

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Description

The invention relates to medicine, namely to surgery, in particular to traumatology and orthopedics, is intended for open reduction and internal fixation of fractures in the lateral condyle of the tibia. Intra-articular comminuted fractures of the lateral condyle of the tibia prevail over fractures of the medial condyle and account for up to 90% of all intraarticular fractures of the proximal tibia. This type of injury is often accompanied by subchondral bone impression, which leads to a structural defect and discongruency in the knee joint. The generally accepted method of treating such fractures is surgical, which consists in open reposition, osteoplasty and rigid fixation of the fracture with support plates.

Known surgical access in the treatment of fracture of the lateral condyle of the tibia, in which, using the position of the patient on the back, a skin incision is made 7-8 cm long from top to bottom, starting about 1.5 cm medial to the head of the fibula and 1 cm distal to the popliteal fold . The subcutaneous tissue and the popliteal fascia are dissected in an acute manner. Dissect the joint capsule and open the cavity of the knee joint (Liu GY, Xiao BP, Luo CF, Zhuang YQ, Xu RM, Ma WH. Results of a modified posterolateral approach for the isolated posterolateral tibial plateau fracture. Indian J Orthop. 2016 Mar-Apr; 50 (2): 117-22. Doi: 10.4103 / 0019-5413.177578).

However, this access does not provide a sufficient view of the external condyle along the length, is associated with dissection of the posterior structures, which can lead to damage to the common peroneal nerve. Also, when performing this access, it seems difficult to adequately position the osseous metal fixator due to the proximity of the location of the proximal segment of the fibula.

Also known is the anterolateral femoral-tibial surgical access to the external condyle of the tibia, including a linear incision from the external epicondyle of the femur to the tuberosity of the tibia. Sequentially dissect the skin, subcutaneous tissue and its own fascia, including the iliac-tibial tract. Further access involves the implementation of a standard submenual arthrotomy of the joint (S. Hoppenfeld, P. deBoer. Surgical exposures in orthopedics: the anatomic approach. Philadelphia. - 2003. - P. 211-213).

However, this access does not provide a sufficient view of the external condyle of the tibia along the length, is associated with dissection of the external capsule-ligamentous structures, as a result of which the bone metal fixator in the proximal part remains covered only by a layer of subcutaneous fat. Also, as a result of dissection of the external capsule-ligamentous structures, their subsequent restoration at the level of the joint space is difficult.

Known lateral surgical access to the knee joint, consisting of a longitudinal section of the skin and soft tissues along the outer surface of the knee joint; access begins from the external epicondyle of the femur and continues until the tibial tuberosity (R. Bauer, F. Kerschbaumer. Operative approaches in orthopedic surgery and traumatology. New York, 1987, p. 156-157). However, such a longitudinal incision leads to the formation of painful postoperative scars that restrict movement in the knee joint.

Surgical access to the lateral condyle of the tibia is known for fractures of the latter, which consists in an L-shaped incision of the skin at the level of the joint space and the formation of a single skin-subcutaneous-fascial-muscle flap (RF patent No. 2525211). However, with this access, the skin branches of the femoral and lateral cutaneous nerve of the calf intersect, which can lead to long-term sensitivity disorders along the lateral surface of the lower leg.

Known for extended lateral surgical access by Tscherne-Johnson (Tscherne-Johnson Extensile Approach for Tibial Plateau Fractures. Eric E. Johnson MD, Step. Clin Orthop Relat Res (2013) 471: 2760-2767 DOI 10.1007 / s11999-013-2962-2 ) Access includes a skin incision in a standard femoral-tibial manner from the epicondyle of the femur towards the tuberosity of the tibia. Sequentially dissect the skin, subcutaneous tissue and its own fascia. Then, an osteotomy of the anteroposterior part of the lateral condyle is carried out in such a way that the latter, together with the iliac-tibial tract, remains intact and is retracted posteriorly.

However, this access involves an osteotomy of the entire external condyle and, even with the ileo-tibial tract preserved, is a highly traumatic intervention. Also, the access does not have a classic submeniscal arthrotomy, which excludes a complete revision of the outer part of the tibia plateau, especially its dorsal sections. After reposition and insertion of the plate, the latter in the proximal part remains covered only with a layer of subcutaneous fat, which can lead to long-term healing of the postoperative wound.

The technical result of the invention is to improve conditions for operations on the knee joint, to create sufficiently spacious and safe access to the external condyle of the knee joint, which allows you to cover the metal fixator with the deep fascia of the lower leg, without disturbing the fascial-ligamentous apparatus of the knee joint in its lateral section.

The claimed technical result is achieved by the fact that in the surgical approach for intraarticular fractures of the external condyle of the tibia, including a soft tissue incision in the form of a half parabola: skin and subcutaneous tissue, the incision is made along the lateral surface of the knee joint from the lateral epicondyle of the femur distally towards the tuberosity the tibia, not reaching the last 2 cm. Next, the cutaneous-subcutaneous flap is cut out in an acute way, which is retracted posteriorly, so that it exposes tsya own fascia and contoured through the fascia bump poles. Next, an L-shaped incision is made of the own fascia, which begins 3 cm proximal to the joint space from the level of the lateral collateral ligament. The incision is conducted parallel to the joint space to the ligament of the patella, after which they are turned perpendicularly and lead in the distal direction to the level of the tibial tuberosity. The resulting fascial flap is sharply peeled off from the underlying capsule of the joint, while an osteotomy of the Zherdy tubercle is performed, which greatly facilitates the separation of the flap. The formed flap is removed in the dorsal direction. A submennal arthrotomy of the knee joint is performed, fracture reposition and osteoplasty are performed. The final fixation is carried out by the support plate. After the osteosynthesis of the fracture in its correct position, the continuity of the fascial-ligamentous apparatus of the knee joint is restored by applying a separate continuous twisted seam to the fascial flap, first in the proximal part (to prevent tissue deficiency), then in the distal, under the fascia, active drainage is established. The skin-subcutaneous flap is sutured with separate interrupted sutures.

The invention is illustrated by drawings.

In FIG. 1 is a copy of a radiograph of the right knee joint in direct projection.

In FIG. 2 is a copy of a radiograph of the right knee joint in lateral projection.

In FIG. 3 is a copy of a CT scan of the right knee in the frontal section.

In FIG. Figure 4 presents a copy of the photograph from the operating room, in which the line of the skin incision is indicated by a dotted line.

In FIG. 5 is a copy of a photograph from the operating room on which a skin-subcutaneous flap is formed that is retracted posteriorly.

In FIG. Figure 6 presents a copy of the photograph from the operating room, in which the L-shaped line of the fascia cut is marked with a coagulator.

In FIG. 7 is a copy of a photograph from the operating room on which an L-shaped fascial flap is formed (the joint capsule is intact), which is retracted with forceps.

In FIG. 8 is a copy of a photograph from the operating room, in which an osteotome is mounted on the outer cortical layer of the Zherdy tubercle.

In FIG. 9 is a copy of a photograph from the operating room, in which a full-layer fascial flap with a fragment of the Zherdy tubercle is laid back, which shows the incision line and surgical access to the damaged condyle of the tibia of the right tibia.

In FIG. 10 is a copy of a radiograph of the right knee joint in direct projection after surgery.

In FIG. 11 is a copy of a radiograph of the right knee in lateral projection after surgery.

In FIG. 12-13 - copies of photographs showing the functions of the right knee joint during flexion and extension of the lower leg 12 months after surgery.

The method is as follows.

A skin incision is made in the form of a figure of half a parabola along the lateral surface of the knee joint area. The incision begins from the external epicondyle of the femur and directs it smoothly in the distal direction to the tuberosity of the tibia, not reaching the last 2 cm. Next, the skin-subcutaneous flap is cut out in an acute way, which is retracted posteriorly so that its own fascia and contouring through the fascia are exposed tubercle of the pole on the outer condyle of the tibia. Next, an L-shaped incision is made of the own fascia, which begins 3 cm proximal to the joint space from the level of the lateral collateral ligament. The incision is conducted parallel to the joint space to the ligament of the patella, after which they are turned perpendicularly and lead in the distal direction to the level of the tibial tuberosity. The common peroneal nerve passes behind the tendon of the biceps femoris, which eliminates the risk of damage to it. The obtained fascial flap is peeled off sharply from the underlying capsule of the joint, while a sliding osteotomy of the Zherdy tubercle is performed, only its outer cortical layer is cut, and subperiosteal retraction of the anterior muscle group of the leg is performed. The formed flap is removed in the dorsal direction. A submennal arthrotomy of the knee joint is performed, then, in conditions of improved visualization of the articular surface, the fracture is repositioned and osteoplasty is performed if necessary, with the final fixation being carried out by the support plate. After the osteosynthesis of the fracture in its correct position (control is carried out intraoperatively using an electronic optical transducer), the fascial-ligamentous apparatus of the knee joint is restored to continuity by applying a separate continuous upholstery suture to the fascial flap, first in its proximal part (to prevent tissue deficiency), then in the distal one; Active fascia is established under the fascia. The skin-subcutaneous flap is sutured with separate interrupted sutures in a standard manner. External immobilization is not used, and after 24 hours, physiotherapy exercises of the lower leg begin.

An example of the method

Patient K., 41 years old. The injury was received on July 4, 2016 as a result of a fall from a stirrup ladder with emphasis on a straightened shin. She was hospitalized in the traumatology department No. 1 of the MAU Central Clinical Hospital No. 24 with a diagnosis of "Impression fracture of the external condyle of the right tibia" (Fig. 1-2). The zone of impression damage in the area of the external condyle of the tibia is determined.

On the tenth day after the reduction of edema and partial resorption of the subcutaneous hematoma, an operation was performed through the proposed fascioplastic access (Fig. 4-9).

Photos of the stages of the operation of patient K., 41 years old: the line of the skin incision is drawn with a dotted line (Fig. 4), a skin-subcutaneous flap is formed, which is retracted posteriorly (Fig. 5); the coagulator outlines the L-shaped cut line of the fascia (Fig. 6); an L-shaped fascial flap is formed (the joint capsule is intact), which is retracted posteriorly with forceps (Fig. 7) and placed with an osteotome on the outer cortical layer of the Zherdy tubercle (Fig. 8); a full-layer fascial flap with a fragment of the tubercle of the Poles laid back (Fig. 9).

To reposition the fragments, the external condyle was elevated, after which a bone defect was formed in the area of the proximal tibia metaphysis; To correct the latter, autoplasty was performed from the site of the iliac crest. For the final fixation of the fracture, an L-shaped support plate was used (Fig. 10-11). Additional fixation was carried out by Kirchner subchondral spokes. Congruency of the right knee joint restored. The restoration of the anatomy of the knee joint and the congruence of its articular surfaces, free movement in the joint, and discomfort during the implementation of the rehabilitation program is achieved. After 12 months at the control examination of the movement in the knee joint in full, painless (Fig. 12-13).

The proposed surgical access to the external condyle of the tibia for osteosynthesis during fractures allows to increase the visibility of the wound, the access allows you to fully cover the metal fixator with a durable fascial flap, which avoids problems with healing of the postoperative wound. In addition, the proposed surgical access allows you to restore the necessary anatomical balance of the fascial-ligamentous apparatus of the knee joint on its outer section, which avoids the development of joint instability and, thereby, prevent the development of post-traumatic gonarthrosis. Moreover, the proposed access provides the necessary visualization of the wound, exposes the fracture site quite widely, and increases the surgeon's field of action, which is important for accurate reposition of lateral condyle fragments. The proposed surgical access is easy to learn, which allows it to be widely used in the daily practice of surgical traumatology and orthopedics.

Claims (1)

Surgical access for intraarticular fractures of the external condyle of the tibia, including a soft tissue incision in the form of a half parabola: skin and subcutaneous tissue from the lateral epicondyle of the femur distally towards the tibial tuberosity, not reaching the last 2 cm, then cutaneous-subcutaneous are cut out in an acute way a flap that is retracted posteriorly in such a way that its own fascia is exposed and the Zherdy tubercle contouring through the fascia, then produce an L-shaped section of its own fascia, which they begin 3 cm proximal to the joint gap from the level of the lateral collateral ligament, the obtained fascial flap is peeled off sharply from the underlying capsule of the joint, while the periosteum tubercle is osteotomy, which greatly facilitates the separation of the flap, the formed flap is diverted to the dorsal direction, and the submeniscal arthrotomy is performed, fracture reposition and osteoplasty are performed; final fixation is carried out with a support plate.

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