RU2848898C1 - Method of fixing olekranon in fractures of the distal metaphyse of the humerus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention can be used for osteosynthesis of the olecranon in complex comminuted intra-articular fractures of the distal metaphysis of the humerus bone. C-shaped access is performed, bending around the outer surface of the olecranon. V-shaped chevron osteotomy is performed. The olecranon is divided into four quadrants. Screws are placed at an angle of 20° in the lower left and upper right quadrants. Interfragmentary intermediate fixation is performed using two Kirschner wires at angles of 70° from bottom to top so that the temporary repositioning wires form a cross at the edges of the olecranon. The bone canal is drilled along the Kirschner wires and 3 mm cannulated screws with washers are inserted. Both screws are tightened alternately with a manual screwdriver. Interfragmentary compression is monitored using an electron-optical converter in frontal and sagittal projections.

EFFECT: to provide optimal bone-to-bone contact area, a high degree of fixation rigidity and counter-lateral compression, which prevents Kirschner wire migration. It is low-traumatic due to the fact that the V-shaped chevron osteotomy provides optimal bone-to-bone contact area and cannulated screw cross-over.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, shoulder and elbow surgery and can be used for osteosynthesis of the olecranon of the same name bones in complex comminuted intra-articular fractures distal metadiaphysis brachial bones.

A method for osteosynthesis of the olecranon and a device for its implementation are known (RU Patent No. 94041543 dated September 20, 1996). The device is intended for compression intraosseous osteosynthesis of olecranon fragments in the case of their fractures or non-unions using a device in the form of a curved loop and double stems made of a shape-memory material. To prevent postoperative complications and facilitate surgical intervention, the pre-straightened structure is inserted into pre-formed channels, the dimensions of which correspond to the dimensions of the device components, and is located almost entirely within the bone (with the exception of the short stems). The entire structure is a loop with parallel curved stems. The shape of the device approximates the internal contour of the olecranon, which allows for constant compression between the fragments by bending the stems and the loop, resting the latter and short stems against the cortical plate of the olecranon.

The disadvantages of this method include the intermediate state of the shape-memory implant during its intraosseous positioning, which is accompanied by changes in the length and shape of the loop, increasing the risk of recurrent fractures and making it impossible to predict the distribution of forces from the stems of the implant within the formed canal. Furthermore, the need to heat the shape-memory metal increases the duration of the surgical session and, consequently, the duration of general or combined anesthesia. Subcutaneous placement of the implant ends may increase the risk of perforation and surgical wound infection.

A known method of osteosynthesis for olecranon fractures (Russian Patent No. 2720483, April 30, 2020) involves the parallel intramedullary insertion of two Kirschner wires from the olecranon apex through the fracture site, forming an additional tension loop. A third, similar wire, previously heat-treated, is used as the tension loop. The inserted end of the heated wire is secured in the formed hole in the cortex of the ulna. The other end of the wire is then grasped and shaped into a U-shaped loop. This method ensures early and full restoration of elbow joint function by adequately fixating the ulnar fracture site.

The disadvantages of this method include its high invasiveness, as it requires extensive access with a high risk of soft tissue injury, which, consequently, increases the risk of infection, hematoma formation, and hypertrophic or keloid scarring in the postoperative period. The need for extensive access is dictated by an attempt to avoid soft tissue contact with the heated metal implant. Furthermore, this method is quite labor-intensive, requiring preliminary annealing of the pin with a gas torch, which further increases the risk of burns to intact skin of the elbow joint, desmogenic contractures, and increases the risk of fire in the operating room.

The closest technical solution chosen as a prototype is the method of osteotomy and subsequent fixation of the olecranon (Patent of the Russian Federation No. 2344779 dated 01/27/2009), in which an L-shaped osteotomy of the olecranon is performed, first performing an incomplete osteotomy of the olecranon along the longitudinal axis in the sagittal plane to the middle of the olecranon, forming channels in the frontal plane for compression screws, and then continuing the osteotomy transversely outward.

The disadvantages of this method include damage to the intact triceps tendon, which has its own anatomical imprint at the apex of the bone, during bone sawing. Furthermore, the L-shaped sawing configuration is technically challenging and may risk conversion to a split line, especially in patients with changes in bone mineral density, such as osteoporosis. Therefore, it is unsuitable for treating geriatric patients. Furthermore, the transverse projection of compression screws from outside to inside greatly increases the risk of injury to the ulnar nerve, which emerges from the cubital canal prior to implantation (when using a guide drill), and may cause transient ulnar nerve neuropathy. All of the above disadvantages can complicate postoperative rehabilitation in patients with a distal humeral metadiaphysis fracture.

The technical result of the proposed invention is the creation of a method free from the above-mentioned disadvantages.

The proposed method for fixing the olecranon of the ulna in fractures of the distal metadiaphysis of the humerus is performed through a C-shaped skin incision that encircles the outer edge of the olecranon of the ulna and begins 4 cm distal to the apex of the process, proximal to the middle third of the humerus. An electric knife or coagulator is used to mark the incision, and an oscillating surgical saw is used to perform a V-shaped chevron osteotomy, with the apex of the triangular shape located in the center of the trochlear notch at an angle of 30° on each side of the notch. This provides access to the trochlea, capitate eminence, and distal metadiaphysis of the humerus. Depending on the nature and complexity of the fracture, open reduction of the fragments and their fixation with plates, angularly stabilized screws, and Kirschner wires were performed. Following this, the triceps brachii musculoskeletal flap with the osteotomized olecranon fragment is returned to the "parent bed" of the V-shaped chevron. The proximal and distal olecranon fragments of the ulna are reduced using two repositioning clamps using a "tang" pattern, eliminating visual and palpable displacement of the fragment stepwise along the osteotomy line. To simplify navigation during pin insertion, the olecranon is divided into four quadrants (Fig. 1). To avoid interference with the intersecting metal structure, the placement of one and two screws at a 20° angle is planned in the lower left and upper right quadrants, respectively. Interfragmentary intermediate fixation is performed using a 1.1 mm Kirschner wire at a 70° angle from below and below from the lateral edge of the olecranon to the medial cortex of the ulna, 1 cm distal to the coronoid process. The Kirschner wire is palpated and allowed to protrude up to 2 mm beyond the cortex to avoid injury to the surrounding soft tissues. The second Kirschner wire is inserted into the right upper quadrant at a 70° angle, from above and below, from the medial edge of the olecranon to the lateral cortex of the ulna, 1 cm distal to the coronoid process (Fig. 2). Thus, the temporary reduction wires form a cross during radiographic evaluation along the edges of the olecranon tuberosity. Next, a 2.2 mm bone canal is drilled through both cortical bone layers using a hand-held surgical cannulated drill and a cannulated drill bit along the first Kirschner wire. The drill bit should be suitable for the 3 mm screw diameter. The length of the resulting bone canal is measured with a depth gauge, after which a thread is cut to the osteotomy line using a T-shaped hand tap to ensure interfragmentary compression. A 4.5 mm countersink is used to insert the screw head 2 mm deeper. The first 3 mm cannulated screw is then inserted with a standard washer for the selected diameter. This ensures a larger contact area with the edge of the olecranon and prevents excessive bone impaction in cases of osteoporosis. The second cannulated screw and washer are inserted in a similar manner. The length of both bone canals and screws corresponds to the individual morphometric parameters of the operated patient. At the end of the procedure, both screws are alternately tightened with a manual screwdriver, achieving satisfactory compression of the V-chevron osteotomy fragments. Repositioning pins are removed. The position of the ulnar fragments is monitored using an electron-optical converter in the frontal and sagittal projections (Fig. 3). The surgical wound is irrigated with two types of antiseptic, and local thermal hemostasis is administered. The joint capsule is sutured along the edges of the olecranon and olecranon muscle, sealing sutures are applied to the triceps tendon area, and then sutures are applied to bring the tissues together, taking into account anatomical conformity. Vacuum aspiration drains are placed, if necessary. The surgical wound is sutured, and aseptic dressings are applied. The operated upper limb is immobilized with a sling.

The invention is explained by the following images, where Fig. 1 is a frontal view of the elbow joint from the olecranon side towards the wrist. Four quadrants are marked to facilitate navigation and the degrees of installation of cannulated screws, where 1 is the radius, 2 is the ulna, 3 is the cannulated screw; Fig. 2 is the elbow joint from the back side. The markings and the degree of osteotomy are shown schematically, where 1 is the radius, 2 is the ulna, 3 is the cannulated screw, 4 is the compression washer, 5 is the humerus; Fig. 3 - elbow joint in sagittal projection, full extension of 180 degrees, with a schematic representation of the osteotomy line and angles of cannulated screws, where 1 is the radius, 2 is the ulna, 5 is the humerus, 6 is the osteotomy line; Fig. 4 - radiographs of the left elbow joint in 2 projections of the early postoperative period. Reposition of the fracture of the distal metadiaphysis of the left humerus, with the location of the posteromedial and posterolateral plates, as well as the implementation of the osteosynthesis method after olecranon osteotomy.

Visible is the reposition of the fracture of the distal metadiaphysis of the left humerus, with the location of the posteromedial and posterolateral plates, as well as the execution of the osteosynthesis method after olecranon osteotomy.

Embodiment of the invention

The patient is positioned prone on an orthopedic table, with the upper limb abducted on a shelf at 90° at the shoulder joint and 90° at the elbow joint. A non-sterile cloth and a hemostatic tourniquet cuff are applied to the upper third of the arm in several passes. After anesthesia develops, the surgical site is cleaned three times with an antiseptic solution, and the patient is draped, a tourniquet is inflated to 250 mmHg. A linear skin incision is then made along the posterior surface of the elbow joint, up to 20 cm long, depending on the individual morphometric parameters of the patient undergoing surgery. The skin incision is made along the lateral edge of the olecranon of the ulna, 4 cm distal to the apex of the process, proximal to the middle third of the arm. The subcutaneous fat and common fascia of the forearm-shoulder segment (fascia brachii and antebrachii) are incised, and the triceps tendon is exposed. Local thermal hemostasis is performed. To visualize the fracture in the distal third of the humerus, a fenestrated approach is chosen along the medial and lateral edges of the triceps tendon. The anconeus muscle is skeletonized along the edges of the olecranon using blunt and sharp techniques and separated from the joint capsule. An electric knife or coagulator is used to mark the area, and an oscillating surgical saw is used to perform a V-shaped chevron osteotomy, with the highest point of the triangular figure located in the center of the trochlear incision (incisura trochlearis). The angle of the saw is 30° on each side. The triceps tendon flap with the osteotomized olecranon fragment is secured with a repositioning pin and retracted proximally toward the shoulder joint. This maneuver provides extensive access to the trochlea, capitate eminence, and distal metadiaphysis of the humerus for the required reduction and fixation with plates, angularly stabilized screws, and Kirschner wires, depending on the nature and complexity of the fracture. The position of the humeral fragments is monitored with an electron-optical converter in the frontal and sagittal projections. The surgical wound is irrigated with two types of antiseptic, and local thermal hemostasis is administered. The triceps tendon flap with the osteotomized olecranon fragment is then returned to its original location in the V-shaped chevron. The proximal and distal olecranon fragments are reduced using two repositioning clamps using a "tang" technique, eliminating visual and palpable displacement of the fragments and stepping along the osteotomy line. The olecranon is divided into four quadrants to facilitate navigation and pin placement (Fig. 1). The placement of one and two screws at a 20° angle is planned in the left lower and right upper quadrants, respectively, to avoid conflict with the intersecting metal structure. The first 1.1 mm Kirschner wire is used for interfragmentary intermediate fixation at a 70° angle from below to above, from the lateral edge of the olecranon to the medial cortex of the ulna, 1 cm distal to the coronoid process. The Kirschner wire is palpated and allowed to protrude up to 2 mm beyond the cortex to avoid injury to the surrounding soft tissue. A second Kirschner wire is inserted into the right upper quadrant at a 70° angle, from superior to inferior, from the medial edge of the olecranon to the lateral cortex of the ulna, 1 cm distal to the coronoid process (Fig. 2). Thus, the temporary reduction wires cross during radiographic evaluation along the edges of the olecranon tuberosity (tuberositas ulnae). Next, a 2.2 mm cannulated hand drill is used to drill the bone canal using the first Kirschner wire. The drill corresponds to the diameter of the 3 mm screw. The length of the resulting bone canal is measured with a depth gauge. A T-shaped hand tap is then used to cut threads to the osteotomy line to ensure interfragmentary compression. A 4.5 mm countersink is used to insert the screw head 2 mm deeper. The first 3 mm cannulated screw with a washer is then inserted. The washer, standard for the selected screw diameter, ensures a larger contact area with the edge of the olecranon and helps prevent excessive bone impaction in cases of osteoporosis. The bone canal is drilled in a similar manner, threads are cut to the osteotomy level, and the second cannulated screw with a washer is inserted. The length of both bone canals and screws corresponds to the individual morphometric parameters of the operated patient. At the end of the procedure, both screws are alternately tightened with a hand screwdriver, achieving satisfactory compression of the fragments of the V-shaped chevron osteotomy. The reduction splints are removed. The position of the ulna fragments is monitored using an electron-optical converter in the frontal and sagittal projections (Fig. 3). The surgical wound is irrigated with two types of antiseptic, and local thermal hemostasis is administered. The joint capsule is closed along the edges of the olecranon and ulnar muscle, the triceps tendon area is sealed, and sutures are then applied to bring the tissues together, taking into account anatomical conformity. Vacuum aspiration drains are inserted, if necessary. The surgical wound is sutured, and aseptic dressings are applied. The operated upper limb is immobilized with a sling.

The advantages of the proposed method over existing ones include the V-shaped chevron osteotomy's optimal bone-to-bone contact area, ensuring a high regeneration index. The crossing of 3 mm diameter cannulated screws ensures a high degree of fixation rigidity and counter-lateral compression, preventing Kirschner wire migration. The simple screw placement technique does not require additional surgical materials or heating in a standard operating room, allowing for routine replication of the proposed method. The method is low-trauma, as it is performed through a single dorsal C-shaped approach to the distal metaepiphysis of the humerus, significantly reducing the risk of injury to adjacent anatomical structures, the peripheral nervous and vascular systems, and soft tissues. The proposed method helps to reduce the risk of developing postoperative complications and infections, and, accordingly, to reduce the time spent on recovery in the postoperative period, and the absence of the need for strict immobilization of the elbow and wrist joints leads to a reduction in the rehabilitation period.

The method of fixing the olecranon of the ulna in fractures of the distal metadiaphysis of the humerus is implemented on modern equipment, using modern technologies and materials.

Clinical example

Patient E., born in 1984, was admitted to the Ya. L. Tsivyan Novosibirsk Research Institute of Traumatology and Orthopedics (NNRITO) of the Russian Ministry of Health on July 23, 2022. His medical history includes the following: he reported a household injury: he fell on his extended left elbow while jumping over an obstacle. He sought medical attention within three hours of the injury at the emergency room of the research institute, complaining of severe pain, crepitus in the lower third of his shoulder, visual deformity of the left elbow, and decreased muscle strength in his left upper limb. A clinical examination and MSCT with 3D reconstruction were performed. Based on the examination results, the clinical diagnosis was: closed intra-articular comminuted supracondylar fracture of the distal metadiaphysis of the left humerus with displacement of fragments (AO/OTA 13 C1). He was treated according to our proposed method. Following this, X-ray examination of the left elbow joint was performed using an electron-optical converter in the operating room. Following transfer from the Emergency and Rehabilitation Center, a two-view X-ray of the left elbow joint was taken using a stationary X-ray machine. This revealed satisfactory reduction of the distal metadiaphysis fracture of the left humerus, with the placement of the posteromedial and posterolateral plates, as well as the implementation of the osteosynthesis method after the Ollerknon osteotomy (Fig. 4). Primary checkpoint: Six weeks after surgery, at a follow-up examination, control X-rays were also taken, which revealed primary signs of osteotomy zone consolidation, the correct position of cannulated screws 1 and 2, and the plates with angular stability of the screws. Immobilization with a sling fixator lasted 4 weeks. Full passive and active flexion of the injured elbow joint was restored using hardware and then manual kinesiotherapy. The second checkpoint was the examination conducted twelve weeks after surgery, with testing using the VAS (2 points), ASES (77), and DASH (34) scales. By week 12, full active flexion and rotation (supination, pronation) of the left elbow joint had been restored, and biceps brachii strength had recovered to 3 points compared to the healthy limb (strength parameters were assessed using a DK-25 isokinetic wrist dynamometer). The patient returned to typical everyday activities at week 6 and to pre-injury physical activity at week 24. At the second follow-up examination, the patient complained of palpable structures under the skin, which were attributed to the asthenic parameters of the patient's constitution. The patient was satisfied with the obtained results.

Claims (1)

A method for fixing an olecranon in fractures of the distal metadiaphysis of the humerus, including performing an osteotomy of the olecranon with abduction of the bone fragment, forming channels in the frontal plane for cannulated screws, characterized in that a single dorsal C-shaped approach is performed, enveloping the outer surface of the olecranon, a V-shaped chevron osteotomy is performed, with the apex of the saw cut located in the center of the block-shaped notch and with saw cut angles extending from it of 30° on each side; the musculoskeletal flap of the triceps tendon with the osteotomized fragment of the olecranon is fixed with a repositioning clamp and moved proximally towards the shoulder joint, after which an open reposition of the humeral fragments is performed and they are fixed with Kirschner wires using plates with angular stability of screws, then the musculoskeletal flap of the triceps tendon with the osteotomized fragment of the olecranon is returned to the parent bed of the V-shaped chevron, the proximal and distal fragments of the olecranon of the ulna are reduced with two repositioning clamps of the "clutch" type, in projection onto the elbow joint from the side of the olecranon in the direction going towards the hand, the olecranon is divided into four quadrants, in the left lower and right upper quadrants at an angle of 20° to the ulna are placed screws, the first 1.1 mm Kirschner wire is used to perform interfragmentary intermediate fixation at an angle of 70° from the bottom up from the edge of the olecranon to the medial cortical layer of the ulna 1 cm distal to the coronoid process, the second Kirschner wire in the right upper cradle is inserted at an angle of 70° from the top down, from the medial edge of the olecranon to the lateral cortical layer of the ulna 1 cm distal to the coronoid process in such a way that the temporary repositioning wires form a cross at the ulnar tuberosity; Using Kirschner wires, bone canals are drilled using a hand-held surgical cannulated drill and a 2.2 mm cannulated drill bit through both cortical layers of bone. The length of the resulting bone canal is measured using a depth gauge. A thread is cut to the osteotomy level using a T-shaped hand tap. A 4.5 mm countersink is used to immerse the screw heads by 2 mm. Then, 3 mm cannulated screws with a washer are installed. Both screws are alternately tightened with a hand screwdriver. Interfragmentary compression is monitored using an electron-optical converter in the frontal and sagittal projections.