RU2814371C2 - Method for locking intramedullary locking nail - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method for distal blocking of an intramedullary lockable nail with a canal during osteosynthesis of long bones consists in the fact that in the position of the patient on the side in the supra-trochanteric region, a layer-by-layer incision is made to the bone, medullary canal is opened with a cannulated curved awl, image intensifier control is performed, a guide pin is inserted through a hole in the cannulated curved awl deep into the medullary canal, the curved awl is removed, closed manual reduction of the fracture is performed until the bone fragments are compared. Guide pin is delivered through both fragments and the image intensifier control is performed. Medullary canal is drilled with intramedullary drills along the guide pin. Required length of the locked nail is measured. Lockable nail is inserted into the medullary canal along the guide pin, and the image intensifier control is performed. Thereafter, a distal target is inserted, a protective guide is inserted into the lower distal opening, into which a trocar is inserted, which reaches the cortical layer of the bone, trocar is removed, a drill guide is inserted into the protective guide, through which a hole is made in the bone through both cortical layers by a drilling pin, penetrating both cortical layers and a hole in the nail. Drilling pin penetration into the lower distal locking hole is controlled by extending the guide pin in the distal direction along the nail canal, it meets the resistance of the drilling pin at the level of the lower distal blocking hole. Thereafter, a diamond-shaped plate and additional metal sleeves are fitted on the protector guide. In the center of the plate there is a hollow cylindrical elevation, inside which there is a hole for the pin and the drill, and along the perimeter of the plate of the device there are through holes, inside of which there is a thread for metal bushings, inside the bushings there is a through hole for a pin. Then, additional fixation pins are inserted percutaneously into the bone through the centering sleeves and holes in the device to prevent displacement of the distal target guide, the protector guide and the drill guide. Further, the pin inserted into the distal blocking hole is removed. Hole in the bone is drilled through a canal formed earlier with a pin by a drill guide, passing through both cortical layers and a hole in the nail. Drill is removed. Measuring device of the locking screw is inserted, a screw of the required length is selected and the locking screw is screwed into the formed hole. Fixation pins, the device for guiding the holes for the distal locking screws and the protective guide are removed. Similarly, the locking screw is delivered through the upper distal locking hole.

EFFECT: invention provides simplifying the technique of distal blocking of intramedullary blocked nails during surgical treatment by the method of intramedullary blockable osteosynthesis, preventing reduction of distal blocking strength, reducing the time of using the image intensifier, thereby reducing the X-ray load on the patient and personnel, reducing the length of the surgical intervention and the composition of the surgical team.

1 cl, 22 dwg, 1 ex

Description

The invention relates to the field of medicine and medical technology, in particular to traumatology and orthopedics, and can be used in the surgical treatment of fractures of long tubular bones using the method of locked intramedullary osteosynthesis.

In traumatological practice, the “Method of distal blocking of rods during intramedullary osteosynthesis of long tubular bones using a distal target using an electron-optical X-ray image converter” is used [In the book: Intraosseous osteosynthesis of the femur. Implants, instruments, surgical techniques. Manufacturer: ChM. Levitske village 3b, 1-b-061 Yukhnowiec K., Poland], which consists in the fact that the formation of channels in the bone with a drill for locking screws is carried out under constant visual control on the monitor of an electron-optical X-ray image converter (EOC) , using a navigation system that projects holes for distal blocking of the rod.

This method has a number of disadvantages. During insertion of a blocked rod into the medullary canal, it often deviates from the midline and passes anteriorly or posteriorly, which ultimately leads to the drill not entering the blocking hole. Such misses lead to increased x-ray load on the patient and medical staff due to the constant use of the electron-optical X-ray image converter, and most importantly, misses and multiple extra holes lead to unstable distal blocking due to weakening of the bone tissue near the blocking holes. All this also leads to an increase in surgical intervention time.

The known method “Device and method for distal blocking of intramedullary rods during osteosynthesis of tubular bones” Patent for invention RU 2253397 C1.

The technical result is achieved in that: a device for directing drilling holes for distal locking screws of intramedullary rods during osteosynthesis of long tubular bones consists of two rings connected to each other by three rods via a detachable connection, and on one of the rings there is a fixed bar with holes for placement in them removable guide sleeve for the drill. The method of using the device involves identifying a hole for a blocking screw in the intramedullary rod and subsequent drilling, placing it on the limb in the area of intended blocking so that the rings are located on the outer and inner sides of the limb, respectively, and the guide removable sleeve is located on the side where the hole is formed, with the drilling point determined by moving the device with X-ray control in the frame-by-frame operating mode of the X-ray electron-optical converter, by means of which the position of the guide sleeve of the device is established in which the hole of the sleeve is projected onto the hole in the intramedullary rod, then in this position the rings are rigidly fixed to the limb. An intramedullary rod is inserted into the damaged bone, after which the device is applied to the limb in the area of intended blocking so that the rings are located on the outer and inner sides of the limb, respectively, and the guide sleeve is on the side where the hole is formed. Next, the position of the guide bushing is established, in which the hole of the bushing is projected onto the hole in the rod by moving the device during X-ray control in the frame-by-frame operating mode of the image intensifier tube. It is in the indicated position of the guide sleeve that the rings are brought together in a measured manner by moving the nuts in the threaded rods until the device is rigidly fixed to the tissues of the limb. After this, drilling is carried out through the guide sleeve without x-ray control.

This method has a number of key disadvantages, namely:

- This method does not use a standard navigation system, which allows you to accurately anticipate the projection location of the blocking hole on the limb;

- Depending on the circumference of the limb, constant remounting of the device is required, which is inconvenient for the surgeon and increases the time of surgical intervention;

- This device requires searching for the blocking hole, both in the frontal and sagittal plane, which can lead to either not hitting the hole the first time or hitting the hole at the wrong angle. This forces the surgeon to repeatedly drill into the bone, which leads to weakening of the bone tissue around the blocking hole, especially in patients with osteoporosis, which in turn leads to unstable distal blocking, due to which further mobility is formed, in the fracture zone leading to delayed consolidation . And inserting a screw into the blocking hole at an incorrect angle leads to the impossibility of dynamizing the fracture, difficulty in removing the blocking screw and its possible breakage.

- This device requires mandatory frequent use of the image intensifier in frame-by-frame mode, which significantly increases the x-ray load on the patient and medical personnel.

The invention we declare, unlike others, has a number of key features and differences:

- Used in conjunction with a standard distal target from the set for locked intramedullary osteosynthesis and does not require its removal;

- It is universal for operations using the method of intramedullary locked osteosynthesis;

- Fixes the protector guide and the 3.5 mm drill guide exactly above the blocking hole, thereby ensuring that the drill, and then the screw, gets into the blocking hole;

- When used in conjunction with the distal target, the locking screw will always be screwed into the locking hole at the correct angle.

- Significantly reduces radiation exposure to the patient and medical personnel and reduces the time of surgical intervention.

- By holding the distal target steady and ensuring the drill hits the distal hole the first time, this avoids drilling unnecessary holes which weaken the bone and reduce the strength of the distal locking.

Objective of the invention:

Creation of a durable, reliable device for simplifying the technique of distal blocking of intramedullary locked rods during surgical treatment using intramedullary locked osteosynthesis, avoiding a decrease in the strength of distal blocking, reducing the time of using the image intensifier, thereby reducing the X-ray load on the patient and staff, reducing the time of surgical intervention and reducing the composition of the operating team .

A method for distal blocking of an intramedullary locking rod with a canal during osteosynthesis of long bones, characterized in that with the patient in the lateral position in the supratrochanteric region, a layer-by-layer incision is made to the bone, the medullary canal is opened with a cannulated curved awl, image intensifier control is carried out, and it is inserted through the hole in the cannulated curved awl deep into bone marrow canal with a guide pin, remove the curved awl, perform a closed manual reduction of the fracture until the bone fragments are compared, pass a guide pin through both fragments, carry out image intensifier control, drill out the bone marrow canal with intramedullary drills along the guide pin, measure the required length of the blocked rod , a lockable rod is inserted into the bone marrow canal along the guide wire, image intensifier control is carried out, then a distal target guide is installed, a guide-protector is inserted into the lower distal hole, into which a trocar is inserted, which reaches the cortical layer of the bone, the trocar is removed, a guide is inserted into the protector guide drills, through which a hole is made in the bone with a drilling pin, passing through both cortical layers and a hole in the rod, the drilling pin is controlled to enter the lower distal blocking hole by moving the guide pin in the distal direction along the canal of the rod, it meets the resistance of the drilling needle held at the level of the lower distal blocking hole, after which a device is put on the protector guide to guide drilling of holes for the distal blocking screws, made in the form of a diamond-shaped plate and additional metal bushings; in the center of the plate there is a hollow cylindrical elevation, inside of which there is a hole for passing a knitting needle and a drill, and along the perimeter of the device plate there are through holes inside of which there is a thread for metal bushings, inside the bushings there is a through hole for passing a knitting needle, then through the centering bushings and holes in the device additional fixation knitting needles are inserted through the skin into the bone to prevent displacement distal target guide, protector guide and drill guide, then remove the wire inserted into the distal blocking hole, drill through the channel previously formed by the wire a hole in the bone with a drill along the drill guide, passing through both cortical layers and the hole in the rod, remove the drill, insert a blocking screw meter , select a screw of the required length and screw the blocking screw into the formed hole, remove the fixation pins, the device for guiding the drilling of holes for the distal blocking screws and the protector guide, and similarly pass the blocking screw through the upper distal blocking hole.

Description of the invention:

The goal is achieved by the fact that after repositioning the fracture, inserting an intramedullary locking rod into the canal, installing a standard distal target guide from the set for locked osteosynthesis and checking that the pin fits into the distal locking hole, the drill guide is placed on the drill guide, our invention is fixed, and through the holes in it it is inserted into the bone additional fixation pins and thanks to this, the possibility of displacement of the distal target guide when changing the pin to a drill is completely eliminated, which allows you not to be afraid of further failure of the drill and the locked screw to enter the distal locking hole, all this facilitates and speeds up the operation, reduces the number of x-ray images taken on the image intensifier, allows reduce the operating team by one person, since it is no longer necessary to hold the distal target still with your hands while changing the wire to the drill. Also, our invention avoids reducing the strength of the distal blocking due to the stationary holding of the distal target and the drill getting into the distal hole stably the first time, this avoids drilling unnecessary holes with the drill which weaken the bone and reduce the strength of the distal blocking.

The technical result is achieved by the fact that the invention is made of stainless steel and consists of a diamond-shaped plate and additional metal bushings. In the center of the diamond-shaped plate there is a hollow cylindrical elevation with a diameter suitable for combining the plate with the drill guide from the standard set for locked intramedullary osteosynthesis; inside the elevation there is a hole for passing the pin and drill. Along the perimeter there are 25 through holes, inside of which there is a thread for metal bushings; at the ends of the bushings there is also a thread for screwing into the holes on the invention. The bushings are used to guide Kirschner wires and center them during their placement; for this purpose, there is a through hole inside the bushings.

The essence of the invention is shown in the graphic material.

Figure 11 shows a femur in the medullary canal in which a lockable rod (15) is inserted, a standard distal target guide (1) is installed, a protector guide (4) and a drill guide (5) are inserted, and a pin ( 3) and the spoke was checked to fit into the hole (9).

Figure 12 shows a femur in the medullary canal into which a locking rod (15) is inserted, a standard distal target guide (1) is installed, a protector guide (4) and a drill guide (5), on which our invention is put on (19), are inserted through the holes in which (20) additional fixation pins (21) are inserted into the bone, and the pin located in the lower distal locked hole is replaced with a drill (8).

Figure 20 shows a photograph of the invention, where:

22 - base in the form of a metal diamond-shaped plate.

23 - central hollow cylindrical elevation with a diameter for connection with the drill guide.

24 - hole in the center of the cylindrical elevation for passing the knitting needle and drill into the blocking hole.

25 - holes on the plate for introducing additional fixation spokes, with threads for screwing in bushings.

26 - bushings for holding Kirschner spokes with threads and a hole in the center.

Figure 21 shows a drawing with characteristics of the invention.

Clinical example of the use of the invention.

The sequence of actions is shown in graphic materials (Figure 1-22).

Patient V., 48 years old, was admitted to the trauma department of the BUZ UR 1RKB MZ UR after an accident (collision of two cars). After collecting complaints, anamnesis data, clinical and laboratory-instrumental examination, a diagnosis was made: a closed fracture of the middle third of the left femur with displacement of fragments along the length and width. The patient was in skeletal traction for two days. On the third day he was taken to the operating room for osteosynthesis of the left femur with a locking rod.

With the patient positioned on the right side, the surgical field was treated three times with ACD solution, a layer-by-layer incision was made to the bone 4 cm long in the supratrochanteric region, hemostasis along the course, the medullary canal was opened with a cannulated curved awl (Figure 1). Image intensifier control. Then, a guide pin is inserted through the hole in the cannulated curved awl deep into the medullary canal (Figure 2), and the curved awl is removed (Figure 3). Then closed manual reduction of the fracture was performed, bone fragments were compared, a guide wire was passed through both fragments, image intensifier control (Figure 4). Then the medullary canal was drilled out with intramedullary drills to a diameter of 10 mm. including along the guide pin (Figure 5), the required length of the locked rod was measured (Figure 6). A 9*360 mm lockable rod was inserted into the bone marrow canal along a guide pin, image intensifier control (Figure 8). Then a distal target guide is installed, a protector guide is inserted into the lower distal hole, a 1 cm skin incision is made, a trocar is inserted into the protector guide, which reaches the cortical layer of the bone (Figure 9), the trocar is removed, a drill guide is inserted into the protector guide, guide, a hole is made in the bone with a needle, passing through both cortical layers and a hole in the rod (figure 10). The control of the needle entering the lower distal blocking hole was carried out: the guide wire is passed in the distal direction along the rod channel, it meets the resistance of the inserted wire at the level of the lower distal blocking hole (Figure 11). The invention is put on the protector guide (Figures 20-21), fixed, and additional fixation pins are inserted percutaneously into the bone through the holes on the site to prevent displacement of the protector guide and drill guide. The pin inserted into the distal blocking hole is removed and a drill is used along the guide, through the channel formed earlier by the pin, to drill a hole in the bone, passing through both cortical layers and the hole in the rod (Figure 12). The protector guide and drill guide fixed by our invention make it possible to avoid the drill and then the screw not getting into the hole, to avoid additional reaming and thereby weakening of the bone, reduces the expected x-ray load and reduces the operation time. Then the drill is controlled to enter the distal blocking hole in the previously described manner (Figure 13). Next, the drill is removed, a screw gauge is inserted, a screw of the required length is selected, and a 45 mm screw is screwed into the formed channel. (figure 14). The additional fixation pins, our invention, and the protector guide are removed. The upper distal locking screw is inserted using a similar technique (Figures 15-19). Image intensifier control is carried out. Then the proximal blocking of the rod is carried out using the standard technique of intramedullary locked osteosynthesis. Image intensifier control. The rod retainer is removed, an M8 plug screw is installed, the wound is cleaned, the wound is sutured layer-by-layer, and an aseptic dressing is applied. The postoperative period was uneventful. Fracture healing in average physiological terms.

This invention has been introduced and successfully used on the basis of the traumatology department of the BUZ UR 1RKB MZ UR of Izhevsk. Using this invention, more than 50 operations of locked intramedullary osteosynthesis were performed. This invention made it possible to facilitate the distal blocking of intramedullary locking rods, reduce the operation time by an average of 10-15 minutes, reduce the use of an image intensifier by 5-8 images per operation, and reduce the operating team by one person.

Claims (1)

A method for distal blocking of an intramedullary locking rod with a canal during osteosynthesis of long bones, characterized in that with the patient in the lateral position in the supratrochanteric region, a layer-by-layer incision is made to the bone, the medullary canal is opened with a cannulated curved awl, image intensifier control is carried out, and inserted through a hole in the cannulated curved awl a guide wire is inserted deep into the bone marrow canal, the curved awl is removed, a closed manual reduction of the fracture is performed until the bone fragments are compared, a guide wire is passed through both fragments, image intensifier control is carried out, the bone marrow canal is drilled with intramedullary drills along the guide wire, the required length is measured blockable rod, a blocked rod is inserted into the medullary canal along a guide wire, image intensifier control is carried out, then a distal target guide is installed, a protector guide is inserted into the lower distal hole, into which a trocar is inserted, which reaches the cortical layer of the bone, the trocar is removed, into the guide protector, a drill guide is inserted, through which a drilling pin is used to make a hole in the bone, passing through both cortical layers and a hole in the rod; the drilling pin is controlled to enter the lower distal blocking hole by placing the guide pin in the distal direction along the rod channel , it meets the resistance of the drilling needle at the level of the lower distal locking hole, after which a device is put on the protector guide to guide drilling of holes for the distal locking screws, made in the form of a diamond-shaped plate and additional metal bushings, in the center of the plate there is a hollow cylindrical elevation, inside of which there is a hole for passing a needle and a drill, and along the perimeter of the device plate there are through holes, inside of which there is a thread for metal bushings, inside the bushings there is a through hole for passing a needle, then through the centering bushings and holes in the device additional fixation devices are inserted percutaneously into the bone wires to prevent displacement of the distal target guide, protector guide and drill guide, then remove the wire inserted into the distal blocking hole, drill through the channel previously formed by the wire, a hole in the bone with a drill along the drill guide, passing through both cortical layers and a hole in the rod, the drill is removed, the locking screw gauge is inserted, the screw of the required length is selected and the locking screw is screwed into the formed hole, the fixation pins, the device for guiding the drilling of holes for the distal locking screws and the protector guide are removed, and the locking screw is similarly passed through the upper distal locking hole.