RU2735998C1 - Method for arthrodesis of subtalar joint in conditions of soft tissue deficiency - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, plastic surgery and can be used for arthrodesis of the subtalar joint in conditions of soft tissue deficiency of calcaneal region. Treatment is performed in one stage. Subtalar joint is accessed from behind. Height of the posterior foot is restored by reducing the heel bone. After introduction of the wedge-like bone autograft into the subtalar joint area, two cannulated screws are introduced through the calcaneal tuberosity and the bone autograft into an ankle bone block. Soft-tissue defect is replaced with a skin-fascial sural graft on the septal and skin branches of the fibular artery.

EFFECT: method enables avoiding the problems with the defect closure and eliminates the risk of wound wound necrosis due to excessive tissue tension ensured by the use of the vascularized islet sural graft.

1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, plastic surgery and can be used for arthrodesis of the subtalar joint in conditions of soft tissue deficiency in the calcaneal region.

Most publications in subtalar arthrosis describe a similar method of arthrodesis, using lateral access to the joint, resection of articular cartilage and replacement of the gap formed with a bone graft [1,2,4,5]. However, the authors of these publications do not mention that after a single-stage stretching of the subtalar joint, it is almost impossible to suture the wound without excessive tension on its edges, which can lead to necrosis of the skin edges and infection of the bone wound. In addition, this method practically excludes the implementation of arthrodesis of the subtalar joint in conditions of soft tissue deficiency such as, for example, scar lesions.

In 2001 Dolgopolov V.V. and Sati Ahmed Sali [3] proposed a two-stage subtalar arthrodesis method, in which, at the first stage, simulating resection of the deformed surfaces of the calcaneus, excision of the subtalar joint cartilage and application of an external fixation apparatus to the foot in order to create a gap between the talus and calcaneus by microdistraction are performed. At the second stage, auto- or alloplasty of the subtalar joint cavity is performed without removing the apparatus.

This operation is a prototype of our proposed method, but unlike it, the intervention is performed simultaneously and without the use of an external fixation apparatus, and the use of a fascial-cutaneous sural flap avoids problems with suturing the defect and eliminates the risk of necrosis of the wound edges due to excessive tissue tension.

The technical result consists in restoring the supporting ability of the limb.

The result is achieved due to the fact that the treatment is performed in one stage; access to the subtalar joint is carried out from behind; restoring the height of the hindfoot by lowering the calcaneus and after introducing a wedge-shaped bone autograft into the subtalar joint, two cannulated screws are inserted through the calcaneus tubercle, a bone autograft into the talus block; replace the soft tissue defect with a fascial-cutaneous sural flap on the septal-cutaneous branches of the peroneal artery.

The illustrations show:

FIG. 1. The heel area, the back of the foot, where: 1 - soft tissue defect;

FIG. 2. - X-ray of the foot, post-traumatic deformity of the calcaneus, arthrosis of the subtalar joint, where: 2 - subtalar joint; 3 - calcaneus; 4 - the height of the back of the foot; 5 - talus;

FIG. 3. - X-ray of the foot after performing arthrodesis of the subtalar joint, bone grafting, fixation with 2 cannulated screws, where: 2 - subtalar joint; 3 - heel bone; 4 - the height of the back of the foot; 5 - talus; 6 - cannulated screws; 7 - bone graft.

FIG. 4. - replacement of the defect with an insular sural flap, where: 8 - insular fascial cutaneous sural flap.

The method of arthrodesis of the subtalar joint in conditions of soft tissue deficiency is as follows. Surgical treatment is carried out in one stage. The operation is performed under a tourniquet on the lower third of the thigh. The incision is carried out along the midline of the posterior surface of the leg over the Achilles tendon up to 10 cm in size. The Achilles tendon is dissected in a Z-shape, the capsule of the subtalar joint is opened along the posterior surface, after which the ligaments connecting the talus and heel bones are dissected. Then, using an osteotome or an oscillator saw, the cartilage is removed and the articular surfaces of the articulating talus and heel bones are aligned. To restore the height of the hindfoot, the calcaneus is brought down and the size of the bone graft is determined to fill the formed defect in the subtalar joint. According to the standard technique, a bone autograft is taken from the wing of the ilium for its entire thickness of 5.0 × 4.0 cm. The graft is divided into two equal parts using an oscillatory saw or an osteotome. Each of the parts of the graft is modeled to a wedge-shaped shape and placed into the formed defect in the subtalar joint so that the spongy substance of the graft is in contact with the spongy substance of the articular surfaces of the calcaneus and talus, and the base of the wedge of the bone graft, formed by the cortical layer, faces posteriorly. The graft is fixed with 2 cannulated screws, which are passed through the calcaneus tubercle, the bone graft into the talus block. After the completion of the stage of work on the formation of arthrodesis of the subtalar joint and restoration of the height of the hindfoot, a plastic stage of replacement of the formed soft tissue defect along the posterior surface of the calcaneal region is performed. To do this, after preliminary marking, a cutaneous-fascial sural flap is isolated on the perforating branches of the peroneal artery, the skin part of which corresponds to the size of the resulting defect. The flap is rotated on the vascular pedicle to the area of the defect and sutured to the edges of the wound, while the donor site is sutured in a line. After that, the limb is fixed in a plaster cast for 3 months until the bone block is formed.

Clinical example.

Patient K., 49 years old, case history 21547, DZ: Incorrectly fused fracture of the calcaneus. Subtalar joint arthrosis. A vicious scar on the outer surface of the heel region. Operation 09/27/15: Arthrodesis of the subtalar joint with bone autoplasty, fixation with 2 cannulated screws, replacement of the defect with an insular fascial-skin sural flap. Surgical intervention was performed under conduction anesthesia. The operation time was 2 hours 10 minutes. The postoperative period was uneventful, the wounds healed by primary intention, complete engraftment of the fascial skin flap was achieved, the sutures were removed on day 21. Immobilization with a plaster cast was carried out for 3 months before the formation of the bone block. After removing the immobilization, a course of rehabilitation treatment (exercise therapy, FTL) was carried out. The pain syndrome was arrested, the support ability was restored, the patient moved without additional support. A good aesthetic and functional result was achieved (after restorative treatment).

List of references

1. Boychev B. et al. "Operative Orthopedics". M., 1961, pp. 721-728.

2. Kaplan A.V. "Damage to bones and joints", 1979, p. 548.

3. Pat. 2164389 RF, (13) C2, 2001, Dolgopolov V.V., Sati Akhmed Sali.

4. Chaklin V.D. "Operative Orthopedics". M., 1964, p. 703.

5. Myerson, M.S. Reconstructive foot and ankle surgery: management of complications. 2nd ed. Saunders; 2010.576 p.

Claims (1)

A method of arthrodesis of the subtalar joint in conditions of soft tissue deficiency, including access to the joint, replacement of a defect in the subtalar joint with a bone autograft with its fixation with wires, characterized in that the treatment is performed in one stage; access to the subtalar joint is carried out from behind; restoring the height of the hindfoot by lowering the calcaneus and after introducing a wedge-shaped bone autograft into the subtalar joint, two cannulated screws are inserted through the calcaneus tubercle and the autograft bone into the talus block; replace the soft tissue defect with a fascial-cutaneous sural flap on the septal-cutaneous branches of the peroneal artery.

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