RU2661714C1 - Method of surgical treatment of fractures of pelvic bones with closed intraosseous osteosynthesis - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to traumatology and orthopedics and may be applicable for surgical treatment of pelvic fracture of the pelvic bones by closed intraosseous osteosynthesis. Intradermal bone fixing means, made in the form of an elongated rod of circular section of two parts, proximal elongated with a rounded end of a part of smaller diameter and a distal part of a larger diameter fixed in the guide mounting device to post by means of an internal thread and made with two through-holes, transverse to its axis, axes of the proximal and distal parts of the bone fixing means are located at an angle of 150–170° to each other in a longitudinal plane perpendicular to plane of the axes of the holes in the distal part of the bone fixing means.EFFECT: method allows you to reduce trauma rate, shorten the period of recovery.1 cl, 23 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics in surgical treatment for closed internal fixation of traumatic fractures of the pelvic bones.

A known method for the surgical treatment of pelvic fractures with closed intraosseous osteosynthesis is that the patient is placed on his back on an X-ray transparent table with a roller under the knee joints in the flexion position, while the bladder is catheterized, the surgical field is treated with a skin antiseptic, which is limited to sterile linen, prepare the electron-optical converter (EOP) for the entire period of the operation, then perform surgical access, Without which, from the side of the intact half of the pelvis, bone fixation device is inserted intraosseously, detachably fixed in a guide installation device made of a horizontal conductor and a stand detachably connected to it, while in the conductor there are two through holes with parallel axes parallel to the stand with a distance between them equal to the distance between the holes coaxial with them in the bone fixer in a position fixed on the guide installation device, said holes being in The inductor is arranged to install a removable tubular adapter in turn with the adapter flanged, the outer diameter of the adapter equal to the diameter of these holes, which is equal to the diameter of the head of the fixing screw, and the inner diameter of the adapter is equal to the diameter of the drill for the latter’s seat, then a skin incision is made in the area the intended installation of the guide for the fixing screws after that through a removable tube adapter, which is alternately inserted into one of the two holes th in the jig, with a drill, holes are formed in the bone, then the drill and removable adapter are sequentially removed and the bone fixation device is locked with self-tapping fixing screws, then the final intraoperative x-ray control of the position of the bone fixation device relative to the anterior pelvic half is performed, then the bone fixation device is freed from the guide installation device and the latter is removed from the surgical wound, stitches are placed on surgical wounds and aseptic a sticker on the seams (patent RU 2572189, IPC АВВ 17/90. Published December 12, 2015, Bull. No. 36).

This technical solution has an inherent set of features that is closest to the set of essential features of the invention, it has an appointment that matches the purpose of the invention and is closest in terms of the result achieved, therefore it is taken as a prototype.

The disadvantage of the prototype is the limited use in the treatment of extended fractures, a long recovery process due to increased invasiveness.

The technical result from the use of the invention is to expand the possibilities of treating extended fractures, shortening the recovery process and reduced trauma.

The following are general and particular significant features characterizing the causal relationship of the claimed solution with the specified technical result based on the prior art.

A method of surgical treatment of fractures of the pelvic bones consists in placing the patient on his back on an X-ray transparent operating table with a roller under the knee joints in the flexion position. Catheterization of the bladder is performed, the surgical field is treated with a skin antiseptic, which is limited to sterile linen. Prepare an electron-optical converter (EPO) for the entire period of operation. Surgical access is performed through which, from the intact half of the pelvis, bone fixation device is inserted intraosseously, which is detachably fixed in a guide installation device made of a horizontal conductor and a stand detachably connected to it. Two through holes are made in the conductor with parallel axes parallel to the strut with a distance between them equal to the distance between the holes coaxial with them in the bone fixation device in a position fixed on the guide installation device. These holes in the conductor are made with the possibility of alternately installing a removable tubular adapter in them with the adapter flanging. The outer diameter of the adapter is equal to the diameter of the indicated holes, which is equal to the diameter of the head of the fixing screw, and the inner diameter of the adapter is equal to the diameter of the drill for the seat of the fixing screw. Then, a skin incision is made in the area of the intended installation of the guide for the fixing screws, after which, through a removable tube adapter, which is inserted into one of the two holes in the conductor one by one, the holes are formed in the bone with a drill. Next, the drill and the removable adapter are sequentially removed and the means for fixing the bones are locked by self-tapping fixing screws. Then perform the final intraoperative x-ray control of the position of the means of fixation of bones relative to the anterior semicircle of the pelvis. Next, the bone fixation device is freed from the guide installation device and the latter is removed from the surgical wound. Sutures on surgical wounds and an aseptic sticker on the sutures. In this case, the patient is placed in the position of bending of the legs in the knee joints 150-170 °, and surgical access is performed in the form of a skin puncture 1 cm long in the middle of the pubic joint. Then, the front upper corner of the pubic bone body in the area of the medial edge of the pubic tubercle just below the pubic crest is reached with the end of the scalpel. After that, through a cylindrical soft tissue protector under the control of the image intensifier tube, in the inlet and outlet projections, a guide needle with a diameter of 2.0 mm is drawn through the upper corner of the pubic bone body along its upper branch intraosseously, ensuring the perforation of the second cortical wall. After that, the anterior cortical wall of the pubic bone is drilled along the guide needle with a cannulated drill 6 mm in diameter, and then the needle and drill are removed. Then, through the performed surgical access from the intact half of the pelvis, bone fixing means is introduced intraosseously, made in the form of an elongated rod of circular cross section of two parts, proximal elongated with a rounded end of a smaller diameter and a distal part of a larger diameter, fixed in the guide installation device to the rack by means of an internal thread and made with two through holes transverse to its axis. In this case, the axes of the proximal and distal parts of the bone fixation device are located at an angle of 150-170 ° to each other in a longitudinal plane perpendicular to the plane of the axes of the holes in the distal part of the bone fixation tool, which is advanced inside the pubic bone until its proximal part is completely immersed in the bone channel inlet view. Next, perform the specified skin incision of the anterior abdominal wall for fixing screws in the form of a puncture 1 cm long, then through a removable adapter inserted alternately into one of the two holes that are placed along the axis of the conductor of the guide installation device, these holes are formed with a diameter of 2.5 mm in the bone at a given angle of 90 ° relative to the means of fixation of bones. After removing the drill and the removable adapter, the means for fixing the bones are blocked by two self-tapping fixing screws with a diameter of 3.5 mm, a length excluding the penetration of the mentioned fixing screws outside the pubic body. Then, after the final intraoperative x-ray control of the position of the means of bone fixation relative to the anterior semicircle of the pelvis, the fixation tool is disconnected from the guide installation device, which is removed from the surgical wound, stitches are placed on the surgical wounds and an aseptic sticker is applied to them.

The implementation of the surgical treatment method according to the invention is illustrated by drawings, where: in FIG. 1 installation of a guide needle; in FIG. 2 - drilling with a cannulated drill; in FIG. 3 - the introduction of fixation; in FIG. 4 - preparation for fixing fixing means; in FIG. 5 - fixed means of fixation; in FIG. 6 - guide installation device; in FIG. 7 - shows a conductor with a partial section; in FIG. 8 - means of fixation, side view; in FIG. 9 - the formation of surgical access to the pubic bone (photo); in FIG. 10 - installation of the guide knitting needle into the distal pubic bone fragment (photo); in FIG. 11 - installation of the guide needle into the distal pubic bone fragment under the control of the image intensifier tube (outlet view) (x-ray); in FIG. 12 - installation of a guide needle into the distal pubic bone fragment under the control of the image intensifier tube (inlet view) (x-ray); in FIG. 13 - reaming of the cortical plate with a cannulated drill along the guide needle (photo); in FIG. 14 - reaming of the cortical plate with a cannulated drill along the guide needle under the control of an electron tube (outlet view) (x-ray); in FIG. 15 - means of fixing the bones in the guide installation device (photo); in FIG. 16 - intraosseous holding of the pin from the distal to the proximal fragment of the pubic bone (x-ray); FIG. 17 is a skin incision of the anterior abdominal wall for fixing screws (photo); on Fig - channel formation in the distal fragment of the pubic bone with a drill diameter of 2.5 mm to lock the pin with screws (photo); in FIG. 19 - pin locking with a self-tapping screw with a diameter of 3.5 mm (x-ray); in FIG. 20 - installation of a fixing screw with a screwdriver through a guide device (photo); in FIG. 21 - final locking of the pin with two self-tapping screws with a diameter of 3.5 mm (x-ray); in FIG. 22 - final control under the image intensifier after fixation of the fracture of the pubic bone by means of fixation (x-ray); in FIG. 23 is a view of the surgical field after suturing of surgical approaches (photo).

A method for the surgical treatment of fractures of 1 pubic bones 2 of the pelvis 3 is that patient 4 is laid on his back on an X-ray transparent operating table with a roller under the knee joints in the flexion position.

Catheterization of the bladder is performed, the surgical field is treated with a skin antiseptic, which is limited to sterile linen.

Prepare an electron-optical converter (EPO) for the entire period of operation.

Surgical access 5 is performed (Fig. 9), through which, from the side of the intact half of the pelvis 3, bone fixation means 6 of the bones 2 are inserted, which are detachably fixed in the guide installation device 7 made of horizontal conductor 8 and stand 9, detachably connected to it.

In the conductor 8, two through holes 10 are made with parallel axes parallel to the strut 9 with a distance S between them equal to the distance L between the holes 11 coaxial with them in the bone fixing means 6 in a position fixed to the guide installation device 7.

These holes 10 in the conductor 8 are made with the possibility of alternately installing in them a removable tubular adapter 12 with flanging 13.

The outer diameter of the adapter 12 is equal to the diameter of the holes 10 in the conductor 8.

The diameter of these holes 10 is equal to the diameter of the head of the fixing screw 14, and the inner diameter of the adapter 12 is equal to the diameter of the drill 15 for the seat of the fixing screw 14.

Then perform a skin incision 17 in the area of the proposed installation of the guide 16 for the fixing screws 14.

After that, through a removable tubular adapter 12, which is alternately inserted into one of the two holes 10 in the conductor 8, the drill 15 performs the formation of holes in the bone 2.

Then drill 15 and removable adapter 11 are successively removed and locking means 5 of bones are locked by self-tapping fixing screws 14.

Then perform the final intraoperative x-ray control of the position of the fixation means 6 bones 2 relative to the anterior semicircle of the pelvis 3.

Next, the fixation device 6 of the bones 2 is released from the guide installation device 7 and the latter is removed from the surgical wound.

While laying down the patient 4 is carried out in the position of bending the legs in the knee joints 150-170 °, and surgical access is performed in the form of a skin puncture 1 cm long (Fig. 9) in the middle of the pubic joint.

Then, the front upper corner of the pubic bone 2 body reaches the end of the scalpel in the area of the medial edge of the pubic tubercle just below the pubic crest.

After that, through the cylindrical soft tissue protector under the control of the image intensifier tube, in the inlet and outlet projections, a guide pin 18 with a diameter of 2.0 mm is drawn through the upper corner of the pubic bone 2 along its upper branch intraosseously (Fig. 10, Fig. 11, Fig. 12) with ensuring the perforation of the second cortical wall.

After that, on the guide spoke 18, the anterior cortical wall of the pubic bone is drilled by a cannulated drill 19 with a diameter of 6 mm (Fig. 13, Fig. 14), and then the spoke 18 and the drill 19 are removed.

Then, through the performed surgical access (Fig. 15, Fig. 16), from the side of the intact half of the pelvis 3, bone fixation device 6 is inserted bones 2, made in the form of an elongated rod of circular cross section from two parts, proximal elongated with a rounded end of the smaller part 20 and the distal part 21 of a larger diameter, fixed in the guide installation device 7 to the rack 9 by means of an internal thread and made with two through holes 11 transverse to its axis.

The axes of the proximal 20 and distal 21 parts of the fixation device 6 of the bones 2 are located at an angle of 150-170 ° to each other (Fig. 8) in a longitudinal plane perpendicular to the axis of the holes 11 in the distal part 21 of the fixation means 6 of the bones 2, which is promoted inside the pubic bone until its proximal part 20 is completely immersed in the bone channel according to inlet view.

Next, perform the specified skin incision 17 of the anterior abdominal wall (Fig. 17) for the fixing screws 14 in the form of a puncture 1 cm long.

Then, through a removable adapter 12, inserted alternately in one of the two holes 10, which are located along the axis of the conductor 8 of the guide installation device 7, these holes are formed with a diameter of 2.5 mm in the bone 2 (Fig. 18, Fig. 19) at a given angle in 90 ° with respect to fixation of 6 bones 2.

After removing the drill 15 and the removable adapter 12, the locking means 6 of the bones 2 are blocked (Fig. 20, Fig. 21) with two self-tapping locking screws 14 with a diameter of 3.5 mm, the length excluding the penetration of the said fixing screws 14 outside the body of the pubic bone 2.

Then, after the final intraoperative x-ray control of the position of the fixation device 6 of the bones 2 (Fig. 22) relative to the anterior semicircle of the pelvis 3, the fixation device 6 is disconnected from the guiding installation device 7, which is removed from the surgical wound, stitches are placed on the surgical wounds (Fig. 23) and carry out an aseptic sticker on them.

Comparison of the claimed technical solution with the prior art known from the scientific, technical and patent documentation as of the priority date in the main and related sections did not reveal a tool that has features identical to all the features contained in the claims proposed by the applicant, including the purpose of the application.

That is, the set of essential features of the claimed solution was not previously known and is not identical to any known technical solutions, therefore, it meets the condition of patentability “novelty”.

An analysis of the known technical solutions in the art showed that the proposed technical solution does not follow explicitly from the prior art for the specialist, since solutions have not been identified that have features that match its distinctive features, or such solutions are identified, but the influence of the distinctive features is not known for the technical result indicated in the application materials.

Those. the claimed solution has features that are not found in the known technical solutions, and the use of these features in the claimed combination of essential features makes it possible to obtain a new technical result - expanding treatment options for long fractures, shortening the recovery process and reducing trauma.

Therefore, the proposed technical solution can only be obtained through a creative approach and is not obvious to the average person skilled in this field, i.e. has an inventive step in comparison with the existing level of technology.

This technical solution is industrially applicable, since its purpose is indicated in the description of the application and the title of the invention, it can be carried out industrially for closed internal fixation in case of traumatic fractures of the pelvic bones.

The invention is practicable and reproducible, and the distinguishing features given in the claims are significant, since they affect the possibility of solving the technical problem indicated in the application and obtaining the technical result provided by the invention, that is, they are in a causal relationship with the specified result and, therefore, are significant.

The invention, as described in each of the claims, can be carried out using the means and methods described in patent RU 2572189, which became public until the priority date of the invention.

In addition, the implementation of the claimed invention is achieved by the implementation of this purpose.

Therefore, the claimed technical solution meets the condition of patentability "industrial applicability", which is also illustrated by the following clinical example of the implementation of this method of treatment, confirming the possibility of obtaining the claimed technical result.

The practical implementation of the proposed method is illustrated by the illustrations presented in FIG. 9 - FIG. 23, which shows surgical treatment by closed internal fixation for traumatic fractures of the pelvic bones.

The implementation of the claimed invention is achieved by the implementation of this purpose, which is confirmed by the following clinical example, showing the possibility of obtaining the claimed technical result.

Patient F., 47 years old, was admitted to the hospital with a fracture of the pubic bones resulting from an accident on the railway.

After preoperative planning, a surgical technique was performed using the claimed method.

Position of patient 4 on his back on an X-ray transparent operating table with a roller under the knee joints in a flexion position of 20-30 °.

Under conditions of combined anesthesia with the aim of controlling diuresis and intraoperative monitoring of bladder damage, a bladder catheterized with a Foley catheter.

The surgical field was treated three times with a skin antiseptic from the middle third of the thighs to the costal arches. The surgical field is limited to sterile linen.

For intraoperative x-ray control, an electron-optical converter (hereinafter referred to as “image intensifier tube”) was used.

The scalpel made surgical access (skin puncture) 5 with a length of 1 cm in the middle of the pubic joint (Fig. 9), while the front upper corner of the pubic bone 2 is reached in the area of the medial edge of the pubic tubercle (tuberculum pubicum) immediately below the pubic crest (crista pubica).

The operating surgeon is located on the opposite side from the site of fracture of the pubic bone 2.

Through the cylindrical soft tissue protector, a guide needle 18 of 2.0 mm diameter was drawn (Fig. 10) through the upper corner of the pubic bone body along its upper branch, intraosseously avoiding perforation of the second cortical wall (Fig. 11, Fig. 12).

On the guide pin 18, the anterior cortical wall of the pubic bone was drilled by a cannulated drill 19 with a diameter of 6 mm (Fig. 13).

Through the performed surgical access 5 from the side of the intact half of the pelvis, the fixation means 6 of the bones 2 fixed in the guiding installation device 7 are introduced intraosseously (Fig. 16).

Using the guide installation device 7, the bone fixation device 6 is advanced inside the pubic bone until the proximal part of the fixation device in the bone canal is completely immersed in an inlet view.

A skin incision (puncture) 17 of the anterior abdominal wall 1 cm long was made in the area of the proposed installation of the guide for the fixing screws 14.

Then, through the removable guide 12 inserted alternately into one of the two holes 10 of the jig 8, holes were formed in the bones through the removable guide inserted into the same guide of the guide installation device with a 2.5 mm drill at a predetermined angle of 90 ° relative to the bone fixation means ( Fig. 18).

After removing the drill 15 and the removable guide 12, the locking means 6 of the bones are locked by two self-tapping fixing screws 14 with a diameter of 3.5 mm of the corresponding length (Fig. 19).

The use of two fixing screws 14 eliminates the migration of the fixation means 6 for the bones inside the bone channel and its rotation around the axis (Fig. 20, Fig. 21).

The final intraoperative x-ray control of the position of the means of fixation of 6 bones 2 relative to the anterior semicircle of the pelvis was performed, which excludes the penetration of the fixing screws 14 passed through the proximal part of the means of fixation of bones 6 into the cavity of the small pelvis (Fig. 22).

Sutures are placed on the surgical wounds (Fig. 23). An aseptic sticker on the seams is performed.

After treatment, the patient was able to move around with crutches.

The example confirms the possibility of implementing the claimed combination of essential features of the claims of the method for the surgical treatment of pelvic fractures with closed intraosseous osteosynthesis with the achievement of the claimed technical result - expanding treatment options for long fractures, shortening the recovery process and reducing the invasiveness of the operation.

The proposed method operated on 10 patients with good results, and in some cases, patients were able to stand on their feet and walk with crutches the day after surgery.

Strong fixation of the pubic bones and their connection with each other by means of fixation 6, fixed in the bone 2 by fixing screws 14 with the possibility of maintaining micromotion in the pubic articulation area and providing physiological fixation by maintaining the amortization function of the posterior pelvis, as well as creating physiological conditions for restoration of the pubic bones with shorter rehabilitation times.

The use of the invention allows to expand the possibilities of treating extended fractures, shorten the recovery process and reduce the invasiveness of surgical intervention.

In addition, the operation is accompanied by minimal risks of intraoperative and postoperative complications and a good functional and cosmetic result (Fig. 23).

Claims (1)

A method of surgical treatment of pelvic fractures with closed intraosseous osteosynthesis is that the patient is placed on his back on an X-ray transparent table with a roller under the knee joints in the flexion position, while the bladder is catheterized, the surgical field is treated with a skin antiseptic, which is limited to sterile linen , prepare the electron-optical converter for the entire period of the operation, then perform surgical access through which the sides of the intact half of the pelvis intraosseously introduce a bone fixer detachably fixed in a guide installation device made of a horizontal conductor and a stand detachably connected to it, while in the conductor there are two through holes with parallel axes parallel to the stand with a distance between them equal to the distance between coaxial holes in the means of fixing the bones in a position fixed on the guide installation device, and these holes in the conductor they can be installed in turn with a removable tubular adapter with the adapter flanged, the outer diameter of the adapter being equal to the diameter of the indicated holes, which is equal to the diameter of the head of the fixing screw, and the inner diameter of the adapter is equal to the diameter of the drill for the mounting location of the fixing screw, then a skin incision is made in the area the intended installation of the guide for the locking screws, then through a removable tube adapter, which is alternately inserted into one of the two holes in the the ductor, the drill performs the formation of holes in the bone, then the drill and the removable adapter are sequentially removed and the bone fixation device is locked with self-tapping fixing screws, then the final intraoperative x-ray control of the position of the bone fixation device relative to the anterior pelvic ring is performed, then the bone fixation device is freed from the guide installation device and the latter is removed from the surgical wound, sutured to the surgical wound and aseptic to a watering can on the seams, characterized in that the patient is placed in the position of bending of the legs in the knee joints 150-170 °, while surgical access is performed in the form of a skin puncture one centimeter long in the middle of the pubic joint, then the front upper corner of the pubic bone body reaches the end of the scalpel in the area of the medial edge of the pubic tubercle just below the pubic crest, then through the cylindrical soft tissue protector under the control of the image intensifier, in the inlet and outlet projections, a guide needle with a diameter of two millimeters is passed through the upper corner ol of the body of the pubic bone along its upper branch, intraosseously, ensuring the safety of the second cortical wall, after that, the front cortical wall of the pubic bone is drilled along the guide needle with a cannulated drill six millimeters in diameter, and then the needle and drill are removed, then through surgical access from the intact half the means of fixation of bones, made in the form of an elongated rod of circular cross-section from two parts, proximal elongated with a round the end of the part of a smaller diameter and the distal part of a larger diameter, fixed in the guide installation device to the rack by means of an internal thread and made with two through holes transverse to its axis, while the axes of the proximal and distal parts of the bone fixation device are located at an angle of 150-170 ° to each other to a friend in a longitudinal plane perpendicular to the plane of the axes of the holes in the distal part of the bone fixation tool, which is promoted inside the pubic bone until its proximal hour is completely submerged and in the bone channel according to inlet view, then perform the specified skin incision of the anterior abdominal wall for blocking screws in the form of a puncture one centimeter long, then through a removable adapter inserted alternately into one of two holes that are placed along the conductor axis of the guide installation device, form the indicated holes in the bone with a diameter of two and a half millimeters at a given angle of 90 ° relative to the means of fixation of the bones, then, after removing the drill and removable adapter, the means of fixation of the bone are blocked with two self-tapping fixing screws with a diameter of three and a half millimeters, the length excluding the penetration of the said fixing screws outside the body of the pubic bone, then after the final intraoperative x-ray control of the position of the bone fixation device relative to the anterior pelvic half, the fixation device is disconnected from the guide installation device, which is removed from operating wounds, suture surgical wounds and carry out an aseptic sticker on them.

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