RU2705230C1 - Method of transfibular access for performance of operations on ankle joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics, and can be used to perform reconstructive-plastic operations on ankle joint at terminal stage of deforming arthrosis, deformities of bones of back foot, as well as in patients with neuropathy of lower extremity to recreate its support capacity. Proposed method of transfibular access for performing operations on the ankle joint includes access, osteotomy and fixation of osteotomized fragment of lateral malleolus. Lateral surgical approach to the external ankle is carried out, leaving intact talofibular and calcaneal fibular ligaments. Oscillatory saw is used to perform a T-shaped osteotomy, in which a longitudinal osteotomy of 8 cm is made from an apex of the lateral malleolus in a frontal plane at angle of 90° in relation to the distal fragment of the fibular bone, dividing the lateral malleolus into halves. Then transverse osteotomy is performed perpendicular to lengthwise osteotomy with direction of sawing in horizontal plane at 45° in relation to anatomical axis of fibular bone with an angle open downwards. Osteotomy is performed from a front edge to a posterior edge of the fibular bone, crossing it completely. Then the apex of the lateral malleolus is completely released from the soft tissues for the subsequent mobilization of the bone fragments without touching the heel-fibular ligament. Then, anterior bone fragment is subsequently rotated, then posterior fragment is rotated. After the main stage of the operation, said distal bone fragments are laid on the maternal bed and fixed with a Lavsan thread, without fixing the distal fragments to the proximal one.

EFFECT: method provides minimizing traumatization of a lateral ligamentous complex of ankle and subtalar joints, restore an anatomical configuration of ankle joint for prevention of postoperative complications without using metal structures for fixation of lateral malleolus due to optimal access and T-shaped osteotomy.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used to perform reconstructive plastic surgery on the ankle joint, in the terminal stage of deforming arthrosis, deformities of the bones of the hind foot, as well as in patients with lower limb neuropathy, to recreate it support ability.

The literature describes many approaches for reconstructive operations on the ankle and subtalar joints, but in practice the lateral access (Adams), which we used as an analogue, consists in performing layer-by-layer access to the lateral ankle with subsequent osteotomy, which, in turn, , it is possible to use in various variations as a bone graft, or to save the outer ankle and perform its anatomical reposition on the mother’s bed, which will allow to preserve the anatomical the shape of the ankle joint [8].

The advantages of this enhanced access include the provision of adequate visualization of bone-cartilage and soft tissue structures in the ankle and subtalar joints. Its main drawback is that when performing this access, there is a complete intersection of the lateral ligament complex of the ankle joint: the anterior and posterior talus-fibular, fibular-calcaneal ligaments, which are responsible for stabilization in the ankle and subtalar joints, and partially for the nutrition of muscle and bone structures .

Closest to the claimed invention is the "Method of arthrodesis of the ankle joint" (RF Patent No. 2446766 from 04/10/2012) proposed by S. Khoroshkov.

The author proposes to produce oblique osteotomy of the fibula from front to back in the frontal plane from the articular fissure of the ankle joint, leaving the anterior portion of the tibia syndesmosis intact. After dissection of the anterior talone fibular ligament, the distal ankle fragment rotates outwards, which allows visualization of the articular surfaces of the ankle and subtalar joints. The advantages of this expanded access include optimal visualization of the surgical intervention area. After the main stage of the operation is completed, the osteotomy fragment of the ankle is repositioned and fixed with a tightening screw and a plate with angular stability. The disadvantage of this method is that with operative access, the important stabilizing anatomical structures completely intersect: the posterior talus-fibular, calcaneofibular ligaments and the posterior portion of the distal tibiofibular syndesmosis, which are static stabilizers of the ankle and subtalar joints, and also lead to impaired blood supply to the talus. . Damage to the above structures can also lead to delayed consolidation of bones in this area or a violation of the formation of bone fusion. In addition, the use of additional metal fixators in this zone leads to the fact that healing of the skin does not always occur favorably, due to the minimal severity in the area of the lateral ankle of the subcutaneous fat.

The technical result of the invention consists in performing optimal access to the ankle joint, which minimizes trauma to the lateral ligament complex of the ankle and subtalar joints, restores the anatomical configuration of the ankle joint for the prevention of postoperative complications without the use of metal structures to fix the lateral ankle.

The technical result is achieved due to the fact that after linear surgical lateral access to the external ankle is performed, the latter is mobilized and, leaving the attachment points of the anterior talon-fibular and calcaneofibular ligaments intact, they produce its T-shaped osteotomy in the frontal plane: the first stage is performed longitudinal osteotomy of the distal fragment from the apex of the lateral ankle to the line of the first osteotomy, dividing it into identical halves in the frontal plane. The length of the osteotomy is 8 cm. The second stage is performed transverse osteotomy, perpendicular to the first. The direction of the saw (osteotome) in the horizontal plane is 45 ° relative to the anatomical axis of the fibula with an angle open to the bottom. The third stage skeletonizes the apex of the lateral ankle from the soft tissues, providing mobility of the bone fragments, leaving the talone-fibular and calcaneofibular ligaments intact. Then, along the line of osteotomy in the frontal plane, the bone fragments rotate as an “open book”. This allows you to visualize the articular surfaces of the ankle and subtalar joints and perform reconstructive intervention. After the main stage of reconstructive intervention is completed, the anterior and posterior fragment of the fibula is repaired and sutured with a dacron thread (diameter 3). The distal fragment of the fibula fixed by lavsan thread is adapted by a tight fit method to the mother bed (into the zone of oblique osteotomy), without performing metal osteosynthesis.

The illustrations show:

Fig 1. Scheme of lateral ankle osteotomy in a direct projection

FIG. 2. Scheme of lateral ankle osteotomy in lateral projection

FIG. 3. The scheme of the ankle joint in direct projection after osteotomy

Fig 4. Scheme of the ankle joint in a lateral projection after performing osteotomy

FIG. 5. Type of surgical wound before osteotomy

FIG. 6. Type of surgical wound during osteotomy

FIG. 7. Type of surgical wound during the implementation of the main stage of the intervention

FIG. 8. View of the surgical wound after the main stage of the intervention is performed - the lateral ankle is stitched

FIG. 9. Radiographs of the patient before surgery in direct projection

FIG. 10. Radiographs of the patient before surgery in lateral projection

FIG. 11. Radiographs of the patient after surgery in direct projection

FIG. 12. Radiographs of the patient after surgery in lateral projection

FIG. 13. Radiographs of the patient after surgery in a direct projection 6 months after surgery in a lateral projection

FIG. 14. Radiographs of the patient after surgery in lateral projection 6 months after surgery in direct projection

The method is as follows: after performing linear surgical access to the lateral ankle, it is isolated, leaving intact attachment points of the anterior talone-fibular and calcaneofibular ligaments (Fig. 5.). Then, in two stages, a T-shaped osteotomy of the fibula in the frontal and horizontal planes is performed, dividing it into the proximal and two distal fragments (anterior and posterior). The first step is to perform a longitudinal osteotomy of the distal fragment from the apex of the lateral ankle to the line of the first osteotomy, dividing it strictly in half into the anterior and posterior fragments. An osteotomy is performed in the frontal plane at an angle of 90 °, relative to the distal fragment of the fibula. The length of the longitudinal osteotomy is about 8 cm (Fig. 6.). The second step is a transverse osteotomy perpendicular to the first. The direction of cut passes in the horizontal plane at an angle of 45 ° relative to the top of the fibula. An osteotomy is performed from the front edge to the posterior edge of the fibula, crossing it completely (Fig. 1., Fig. 2.). Next, the third stage mobilizes the tip of the outer ankle from the soft tissues for subsequent mobility of the bone fragments, without affecting the calcaneo-fibular ligament. Then, the anterior distal fragment of the osteotomy fibula is rotated first, then the posterior one. Visualize the articular surfaces of the ankle joint for the necessary reconstructive interventions or arthrodesis of the ankle joint (Fig. 3., Fig. 4., Fig. 7., Fig. 9.). After the manipulations, the front and back of the distal fragment of the fibula are sewn together with vicryl and the resulting whole distal fragment is placed under the proximal into the tibia to recreate the anatomical shape of the ankle joint without the use of metal structures (Fig. 8., Fig. 12.).

The method allows to visualize completely ankle and subtalar joints at the same time, preserve the periarticular soft tissues (tendons of the peroneal muscles, the anterior and posterior tibial-fibular and calcaneofibular ligaments remain intact) and neurovascular formations, fully perform resection of the articular surfaces, eliminate deformation, if any there was, while maintaining the anatomical shape and aesthetic features of the ankle joint.

Clinical example.

Patient S., 58 years old, was admitted with a diagnosis of aseptic necrosis of the right talus. The patient was clinically and radiologically examined, prepared for surgical treatment (Fig. 9., Fig. 10.). During the operation, a T-shaped osteotomy of the lateral ankle of the right lower leg was performed according to the proposed method, the talus with signs of aseptic necrosis was visualized (Fig. 9.). The joint surfaces of the ankle and subtalar joints were resected and fixed with an intramedullary shaft with blocking by screws through the calcaneus. After the main stage of the operation was completed, the distal fragment of the lateral ankle was repositioned and its osteosynthesis was performed with a transossally non-absorbable suture 2.0, after which the distal fragment was returned to the mother’s bed without fixing it with the proximal fragment of the fibula (Fig. 8., Fig. 11., Fig. 12.). The patient underwent gypsum immobilization of the right lower limb with the rear splint from the fingertips to the upper third of the leg for a period of 6 weeks.

The postoperative period was uneventful. Three months after the operation, according to the results of the control examination and radiography, fusion in the osteotomy of the lateral ankle and the formation of bone ankylosis between the tibia, talus and calcaneus were noted.

The patient notes an improvement in the quality of life: pain in the ankle joint has decreased, there is no deformation, it is comfortable when walking and wearing shoes. (Fig 13., Fig 14.)

Bibliography

1. ADAMS J.C. Arthrodesis of the ankle joint; experiences with the transfibular approach. / J. C. ADAMS // J. Bone Joint Surg. Br. - 1948. - T. 30V - No. 3 - 506-11 c.

2. Nihal A. Ankle arthrodesis // Foot Ankle Surg. - 2008. - T. 14. - No. 1. - 1-10 c.

von

Ankzlosen bildung an paralytischen Gleidmassen. / E. Albert // Weiner Medizin ische Press - 1882. - T. 23 - 726-728 c.3. Albert E. Einige

von

Ankzlosen bildung an paralytischen Gleidmassen. / E. Albert // Weiner Medizin ische Press - 1882. - T. 23 - 726-728 c.

4. Myerson M.S. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. / M. S. Myerson, G. Quill // Clin. Orthop. Relat. Res. - 1991. - No. 268 - 84-95 c.

Claims (1)

Method of transmalocular access for performing operations on the ankle joint, including access, osteotomy and fixation of an osteotomized fragment of the lateral ankle, characterized in that they provide lateral surgical access to the external ankle, leaving intact talone-fibular and calcane-fibular ligaments, -shaped osteotomy, during which a longitudinal osteotomy with a length of 8 cm is performed from the top of the lateral ankle in the frontal plane at an angle of 90 ° relative to the distal fragment of the fibula, dividing the lateral ankle in half, then transverse osteotomy is performed perpendicular to the longitudinal osteotomy with a cut direction in the horizontal plane at an angle of 45 ° relative to the anatomical axis of the fibula with an angle open downwards, while the osteotomy is performed from the front edge to the posterior edge of the fibula bone, crossing it completely, after which the apex of the lateral ankle is completely freed from the soft tissues for subsequent mobilization of the bone fragment nt, without affecting the calcaneal-fibular ligament, then the front bone fragment is first rotated sequentially, then the posterior fragment, and after the main stage of the operation, these distal bone fragments are placed on the mother’s bed and fixed with dacron thread, without fixing the distal fragments to the proximal.

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