RU2846160C1 - Method for surgical correction of vena cava by removing navicular bone with osteotomy of cuboid bone - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention relates to medicine, specifically to orthopaedics and traumatology, and can be used for surgical correction of plantar foot. Approach is approached through a medial surface of foot by means of incision approximately 5 cm long along a navicular along a posterior tibial tendon. That is followed by separating and removing a navicular bone, inserting a K-wire through the wound in the area of the removed navicular bone from the medial side into a cuboid bone, said K-wire serving as a reference point for determining an apex of the closed-angle osteotomy and positioning sawdust for correcting cavus and varus of the forefoot. Closed-angle osteotomy of a cuboid bone is performed; the forefoot is brought into a dorsiflexion position, and the corrected position of the forefoot is fixed with K-wires or shape-memory braces.

EFFECT: method provides reduced probability of degenerative changes in foot joints, reduced period of healing and rehabilitation, as well as correction of cavovar deformation and reducing the height of the longitudinal arch of the foot by eliminating the main element of the rigid deformation of the forefoot, completely removing the navicular bone and performing a closed-angle osteotomy of the cuboid bone.

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Description

The invention relates to medicine, in particular to orthopedics and traumatology, and can be used for surgical treatment of hollow feet with pronounced rigid deformation caused by pathology of the forefoot. The invention consists in complete removal of the navicular bone, which eliminates the main element of rigid deformation of the forefoot. Closed-angle osteotomy of the cuboid bone is performed to correct the cavovarus deformation and reduce the height of the longitudinal arch of the foot. The method reduces the likelihood of degenerative changes in the joints of the foot, allows to shorten the healing and rehabilitation period.

Level techniques

In most cases, with a hollow foot, the apex of the deformation is in the area of the Chopart joint. Therefore, the standard method of surgical treatment of a hollow foot caused by deformation of the forefoot is the closed-angle osteotomy of the midfoot Cole and its modifications. Osteotomy of the midfoot is currently an effective technique in surgery of a hollow foot [1]. At the same time, osteotomies have standard complications associated with the features of this type of surgery. The most typical complications are insufficient correction or excessive correction when performing cuts, delayed consolidation or formation of a pseudoarthrosis in the osteotomy area, failure of fixators, arthrosis of the joints of the foot. Also, when performing a closed-angle osteotomy of the midfoot, it is necessary to release soft tissues: release of the plantar fascia, release of internal ligamentous structures, which requires wide access and increases the time of the operation. Osteotomy of the midfoot requires significant bone intervention and increases the risk of postoperative complications [2].

Arthrodesis of the joints of the foot - used in severe forms of deformation, but lead to a significant loss of mobility and increased load on adjacent joints. Tendon transfer - used in combination with bone interventions to balance muscle tone, but does not always provide lasting correction [3].

A method for eliminating equinopolytic foot deformity RU2456952C1 [4] is known, in which an osteotomy of the midfoot is performed in the projection of the neck of the talus with the taking of a wedge-shaped transplant with its base facing the back of the foot and an additional osteotomy of the posterior part of the calcaneus is performed with the taking of a second wedge-shaped transplant with its base facing the back of the foot. However, the method differs in the need to obtain two differently directed transplants.

Another method of eliminating hollow foot deformity was proposed in 1984 by Ilizarov G.A., which consists of osteotomy along one line of the navicular bone from its upper surface downwards and backwards, the talus and the anterior part of the calcaneus, and gradual bringing the foot into a functional position [5]. The method is characterized by trauma and duration of treatment.

Disadvantages of existing methods include a long rehabilitation period, a high risk of overcorrection or undercorrection, complications in the form of arthrosis of the joints of the midfoot and ankle, as well as limited functionality of the foot.

Essence inventions

The invention is aimed at creating a new method of surgical treatment of hollow feet, which allows to avoid extensive surgical access, eliminates the need for volumetric release of soft tissues, provides anatomically precise correction of the deformation of the forefoot, reduces the likelihood of degenerative changes in the joints of the foot (Fig. 1 A). In addition, the invention allows to reduce the healing and rehabilitation period.

The key advantage of this method is the elimination of the main rigid deformation of the forefoot by removing the navicular bone. This reduces the likelihood of degenerative changes in the joints of the foot and prolongs their functional preservation.

The essence of the invention

The surgical correction of flat feet involves surgical access through the medial surface of the foot; isolation and complete removal of the navicular bone, which eliminates the main element of the rigid deformation of the forefoot (Fig. 3A). Next, a closed-angle osteotomy of the cuboid bone is performed, which allows for the correction of the cavovarus deformation and a decrease in the height of the longitudinal arch of the foot (Fig. 4B). The forefoot is fixed in the corrected position using Kirschner wires or shape memory staples.

Here is the protocol of the operation: after 3-fold treatment of the surgical field with antiseptic solutions, an incision is made along the medial surface of the foot along the navicular bone along the tendon of the posterior tibial muscle, about 5 cm long. The tendon of the posterior tibial bone is cut off from the place of attachment to the navicular bone, at the end of the operation it is fixed to the medial cuneiform bone. The talonavicular and navicular-cuneiform joints are identified. Arthrotomy of these joints is performed. The navicular bone is completely removed using an osteotome and nippers. When removing the navicular bone, special attention is paid to careful handling of the articular surfaces of the cuneiform and talus bones. Through the same access along the medial surface of the foot, the calcaneocuboid and metatarsocuboid joints are identified. Through the wound in the area of the removed scaphoid bone, a Kishner wire is inserted into the cuboid bone from the medial side to determine the apex of the closed-angle osteotomy and the position of the cuts for the correction of the cavus and varus of the anterior section. Using the wire as a guide, an osteotomy of the cuboid bone is performed using a special power tool, the resection size is determined individually. They make sure that there are no bone fragments of the scaphoid bone and fragments in the area of the cut of the cuboid bone. Then the forefoot is brought into dorsiflexion and the defect in the area of the scaphoid and cuboid bones is closed. Fixation is performed with wires and the position is checked on an electron-optical converter. Then fixation is performed using a shape memory bracket, preventing its penetration into the articular surfaces, or using a plate. The plate is installed along the medial surface of the talus and medial cuneiform bone, the plate is fixed with screws. Less commonly, the pins are left in place as a final method of fixation. The posterior tibial tendon is transosseously fixed to the medial cuneiform bone. The wound is abundantly washed. Layer-by-layer wound suturing. Aseptic dressing. Immobilization of the foot and ankle in an orthosis.

The results of correction are monitored using radiography during surgery. If necessary, lateralizing osteotomy of the calcaneus is performed if the varus component of the hindfoot deformity remains.

Postoperative care and rehabilitation includes early mobilization, fixation in a plaster cast and subsequent use of individual orthopedic insoles.

A distinctive feature of the method is the preservation of the articular surfaces of the talus and cuneiform bones, which allows for the formation of a new joint and restoration of normal biomechanics of the foot without significant loss of mobility.

Brief description drawings

Fig. 1 - Typical cavovarus deformity of the foot, where

A - general view of the foot of a patient suffering from Charcot-Marie-Tooth disease;

B - Typical cavovarus foot deformity in a patient with Charcot-Marie-Tooth disease.

Fig. 2 - Radiography of the foot in the lateral projection. 1. - The angle of inclination of the calcaneus, the angle between the plantar edge of the calcaneus and the supporting surface. The normal value of the angle is less than 25 degrees. A value of more than 30 degrees is characteristic of a hollow deformity of the rear foot (calcaneocavus). 2. The Meary angle between the long axis of the first metatarsal bone and the long axis of the talus. The normal value of the angle is 0 degrees. In the presence of a hollow deformity, the value of the angle is increased. The long axes of these bones intersect each other in the area of the apex of the deformity (most often - the dorsal surface of the 1 cuneiform bone). The presence of plantar flexion of the 1 metatarsal bone can be assumed.

Fig. 3 - Scheme of removal of the scaphoid and osteotomy of the cuboid bone, where

A - dorsal view, removal of the scaphoid bone;

B - lateral view, osteotomy of the cuboid bone.

Fig. 4 - Scheme of osteotomy of the cuboid bone, performed along a guide pin, where

A - schematic representation of the fixation of the cuboid bone in the dorsal projection;

B - schematic representation of osteotomy of the cuboid bone in lateral projection.

Fig. 5 - Image of intraoperative X-ray control.

Technical result

By using the proposed method, the effectiveness of surgical correction of hollow feet is increased due to precise anatomical reconstruction, the trauma of the operation is reduced, and the risk of hypercorrection or insufficient correction of the deformity is reduced.

In addition, the healing period is reduced from 8-10 weeks (with Cole osteotomy) to 6 weeks. The likelihood of developing arthrosis of the midfoot joints is reduced. Functional results according to the AOFAS scale are improved (from 45 points to 91 points).

One year after the operation, an increase in the AOFAS scale is noted, which indicates good foot function after the operation. The severity of pain decreases according to the VAS scale from 4.7 to 2.1 on average. The GAIS scale indicators also do not change over time. In one year, patients have completely scarred tissue, the foot adapts to the new biomechanics. The obtained indicators prove a good functional result of the operation.

Examples implementation inventions

Example 1

A 23-year-old female patient with idiopathic hollow foot. Pain syndrome - 3.9 on VAS, functional index on the AOFAS scale - 46 points. The patient complained of pain during long walks, difficulties in choosing shoes, and a cosmetic defect. The idiopathic form of the disease was diagnosed.

Surgery was performed according to the stated method. The navicular bone was removed with osteotomy of the calcaneus. Six weeks after the surgery, the pins were removed and a control X-ray was performed, after which the patient began to develop active movements. After 12 weeks, the patient received individual orthopedic insoles. Three years after the surgery, AOFAS - 93 points, pain syndrome - 2.8 according to VAS.

Example 2

A 33-year-old patient with bilateral hollow feet due to Charcot-Marie-Tooth disease. The patient complained of pain and discomfort in the middle section of the right foot for 3 years. Correction was performed using the stated method. The navicular bone of the right foot was removed with corrective osteotomy of the cuboid bone with a fixing plate. After the operation, an ankle orthosis was installed on the right foot. Two years after the operation - AOFAS 90 points, stable correction of the deformity, patient satisfaction.

Sources information

Deben SE, Pomeroy GC. Subtle cavus foot: diagnosis and management. J Am Acad Orthop Surg 2014;22(8):512-20.

Ingram A.J. Paralytic disorders. In: Crenshaw AH, editor. Campbell's orthopedics, vol. 4, 7th edition. St Louis (MO): Mosby; 1987. p. 2925-3061.

Jahss MH. Evaluation of the cavus foot for orthopedic treatment. Clin Orthop Rel Res. 2013; 181:52-63.

Mukhamadeev A.A. Patent RU2456952C1. Method for eliminating equinosexual foot deformity. Federal State Institution "Saratov Research Institute of Traumatology and Orthopedics" Federal State Institution "SarNIITO" 2012.07.27.

Ilizarov G.A., Patent SU 1 178 430 A1. Method for eliminating hollow foot deformity. Filed 1984.02.29. Publication: 1985.09.15.

Claims (4)

1. A method for surgical correction of flat feet, which includes access through the medial surface of the foot with an incision approximately 5 cm long along the navicular bone along the course of the tendon of the posterior tibial muscle, isolation and removal of the navicular bone, installation of a Kirschner wire through the wound in the area of the removed navicular bone from the medial side into the cuboid bone, which serves as a landmark for determining the apex of the closed-angle osteotomy and the position of the cuts for correction of the cavus and varus of the forefoot, performing a closed-angle osteotomy of the cuboid bone, bringing the forefoot into a position of dorsiflexion and fixation of the corrected position of the forefoot using Kirschner wires or shape memory staples. 2. The method according to item 1, characterized in that a lateralizing osteotomy of the calcaneus is additionally performed with control of the position of the bone structures using radiography. 3. The method according to claim 1, characterized in that the surgical access is performed with minimal damage to soft tissues, eliminating the need for extensive soft tissue release. 4. The method according to item 1, characterized in that stabilization of the forefoot after osteotomy is carried out without the use of additional fixation.