RU2835335C1 - Osteoplastic transfemoral amputation method - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, and can be used for osteoplastic transfemoral amputation. Anterior and posterior flaps are cut out from the skin at the level of the knee joint. Patellar ligament is transected at the point of its attachment to the tibia. After incising lateral walls of the superior turn, the anterior flap containing the patella is inverted with its inner surface anteriorly, and the cartilaginous surface of the patella is resected with an oscillating saw. Tissue of posterior surface of knee joint is dissected with amputation knife. Distal femoral metaepiphysis is skeletonized and its osteotomy is performed so that its plane passes horizontally in a standing position. In the frontal plane, the osteotomy is performed parallel to the trans-supracondylar line so that the osteotomy plane coincides with the anatomical distal femorolateral angle, and in the sagittal plane it is perpendicular to the anatomical axis of the femur, wherein the level of osteotomy of the femur is determined by the absence of corrugation of the soft tissues of the anterior surface of the thigh after the test transposition of the patella on sawdust. Then the patella is fixed to the femoral bone file with two cortical tightening screws with diameter of 4.5 mm with a partial thread, which are inserted through the channels drilled with diameter of 3.2 mm and 4.3 mm, marked with 4.5 mm tap in the patella and femur, in the patella-thigh direction, with the patellar insertion points processing by the countersink for the screw head. Patellar ligament is sutured with tendons of muscles of the posterior thigh group.

EFFECT: method provides creation of rigid and stable fixation of patella, which allows to start prosthetics as soon as possible after postoperative wound healing due to creation of long hip stump acting as large and functionally advantageous lever for prosthesis control.

1 cl, 4 dwg, 1 ex

Description

The invention relates to the field of medicine, namely to traumatology and orthopedics, and is intended for the treatment of patients with avulsions and destructions of the lower limbs, for whom transtibial amputation is impossible. This operation is also performed for irreversible ischemia due to damage to blood vessels and extensive damage to other tissues, with prolonged compression syndrome, if it is necessary to perform reamputation (mine-explosive wound, amputation due to progressive wound infection, vicious stump of the shin), when transtibial amputation is impossible.

The invention is a modification of the well-known Gritti-Shimanovsky operation (R. Gritti, Italian surgeon, 1828-1920, Yu.K. Shimanovsky, Russian surgeon, 1829-1868) - osteoplastic supracondylar amputation of the femur, which involves transposition of the patella to the end of the femoral stump. This operation was proposed by Gritti in 1857, developed in detail by Yu.K. Shimanovsky (1863) and, independently of him, by Stokes (W. Stokes, 1863), and improved by I.F. Sabaneev (1890), A.A. Abrazhanov (1898), G.A. Albrecht (1928).

Gritti-Szymanowski amputation significantly improves the characteristics of the femur stump in comparison with the classic transfemoral amputation by creating a supporting end of the stump. This provides the possibility of functional prosthetics of the lower limb by forming a longer stump and transferring the support point from the areas of the greater trochanter and ischial tuberosity.

However, this operation has significant disadvantages:

1. The patella is fixed to the femur with suture material. At the current stage of development of traumatology and orthopedics, taking into account the studied mechanisms of reparative osteogenesis and the principles of fracture treatment developed on their basis, it becomes clear that the formation of bone ankylosis between the patella and the femur in conditions of insufficiently stable fixation requires long periods of time, which in turn significantly extends the overall duration of treatment and delays the stages of therapeutic and training and primary-final prosthetics.

2. Gritti-Schimanowski osteoplastic amputation is trans-condylar, which, taking into account the subsequent transposition of the patella, leads to an excessive length of the femoral stump. The location of the end of the femoral stump practically at the level of the gap of the contralateral knee joint significantly limits the functional capabilities of the prosthesis due to the lack of space for placing the flexion and rotation modules, leads to an inevitable lengthening of the prosthetic limb, different-level arrangement of the flexion axes of the contralateral knee joint and the flexion module of the prosthesis, as well as the need to correct the different heights of the limbs by wearing orthopedic shoes.

The aim of the invention is to develop a method for osteoplastic transfemoral amputation, ensuring the formation of a femoral stump suitable for functionally advantageous prosthetics.

The set goal is achieved by the fact that in the method of osteoplastic transfemoral amputation, anterior and posterior flaps are cut out of the skin at the level of the knee joint, anterior and posterior flaps are cut out of the skin at the level of the knee joint, the patellar ligament is intersected at the place of its attachment to the tibia, after incising the lateral walls of the upper fold, the anterior flap containing the patella is turned out with its inner surface forward, the cartilaginous surface of the patella is resected with an oscillating saw, then all tissues of the posterior surface of the knee joint are dissected with an amputation knife; then the distal metaepiphysis of the femur is skeletonized and its osteotomy is performed in such a way that its plane passes horizontally in the patient's standing position, while in the frontal plane the osteotomy is performed parallel to the supracondylar line so that the plane of the osteotomy coincides with the anatomical distal femorolateral angle, and in the sagittal plane it is perpendicular to the anatomical axis of the femur, and the level of the osteotomy of the femur is determined by the absence of corrugation of the soft tissues of the anterior surface of the thigh after the test transposition of the patella onto the saw; then the patella is fixed to the femur file with two 4.5 mm diameter cortical lag screws with partial threads, which are inserted through pre-drilled channels with 3.2 mm and 4.3 mm diameter drills, marked with a 4.5 mm sword in the patella and femur, in the patella-femur direction, with countersinking of the entry points on the patella under the screw head, while the screws are inserted at a position as close as possible to the perpendicular from the plane of the femur osteotomy; then the patellar ligament is sutured with the tendons of the posterior thigh muscles.

The choice of the type and size of screws, the diameter of the drilled channels are determined by the technology of osteosynthesis of simple fractures, which requires achieving interfragment compression and absolute stability [Thomas P. Ruedi. AO - principles of fracture treatment / Thomas P. Ruedi, Richard E. Buckley, Christopher G. Moran. - Wassamedia, 2013. - Vol. 1. - 636 p.].

The invention is explained in Fig. 1, which shows the formation of a short posterior cutaneous-fascial flap, Fig. 2 shows the execution of an osteotomy parallel to the supracondylar line, Fig. 3 shows a diagram of fixation of the patella to the femur sawing with two screws: A - amputation diagram (the removed bone sections are hatched), B - the part of the patella remaining after the sawing on the anterior flap is transferred to the femur sawing (indicated by the arrow), C - holes for the screws are drilled with a drill at an acute angle of less than 90 degrees, D - the outer cortex of the patella is processed with a countersink for the screw heads, D - fixation of the patella with two screws is performed. Fig. 4 shows: A - primary radiographs, B - radiographs after exarticulation, C - radiographs after the operation and the external appearance of the stump.

The first stage involves performing an arthrotomy of the knee joint using an arcuate horizontal incision. The patellar ligament is dissected from the apex. The patella is mobilized. Next, the collateral, cruciate ligaments, and posterior sections of the knee joint capsule are successively transected. The popliteal artery and accompanying veins are sutured and ligated, the tibial and common peroneal nerves are cut off. The medial and lateral heads of the gastrocnemius muscles are dissected from the fixation site, and then the skin of the posterior surface of the knee joint is transected, forming a short posterior cutaneous-fascial flap (Fig. 1).

The distal metaepiphysis of the femur is skeletonized and its osteotomy is performed at a distance of 8-10 cm proximal to the knee joint space in such a way that its plane passes horizontally in the patient's standing position. For this purpose, in the frontal plane, the osteotomy is performed parallel to the supracondylar line in such a way as to coincide with the anatomical distal femorolateral angle, and in the sagittal plane - perpendicular to the anatomical axis of the femur (Fig. 2).

Fig. 2 shows a diagram of the anatomical and mechanical axes of the femur.

In Fig. 2 the following designations are used:

1 - femur

2 - patella

3 - tibia

7- axis of the femur

8 - mechanical axis of the limb

9 - axis of the tibia

10 - osteotomy level (performed parallel to the supracondylar line)

11 - anatomical distal femorolateral angle (ADFLA) = 81±2°

12 - anatomical femorotibial angle (AFTA) = 173-175°

13 - anatomical proximal mediatibial angle (APMT) = 87±3°

14 - anatomical distal lateral tibial angle (ADLT) = 89±3°

15 - ankle joint line

16 - mechanical distal femorolateral angle (MDFLA) = 87±3°

17 - mechanical proximal mediatibial angle (MPMA) = 87±3°

18 - mechanical distal lateral tibial angle (MDLTA) = 89±3°.

The articular surface of the patella is resected and transposed to the end of the femoral stump with provisional transcutaneous fixation using a Kirschner wire. Femoropatellar arthrodesis is completed with final fixation of the patella with two cortical screws of 4.5 mm diameter. For this purpose, two through channels are formed through separate 0.5 cm long incisions above the anterior surface of the patella with a 3.2 mm diameter drill in the direction as close as possible to the perpendicular from the plane of the femur osteotomy. The inlet openings of the channels are located on the anterior cortical plate of the patella, and the outlet openings are, respectively, on the lateral and medial cortical plates of the diaphyseal part of the femur. Next, using a 4.3 mm diameter drill, the channels in the patella are widened, and then recesses are formed in its anterior cortical plate with a countersink, intended for immersion of the screw heads. Screws are inserted sequentially, achieving interfragment compression and absolute stability (lag screw).

The surgical wound and short accesses for insertion of lag screws are drained and then sutured.

The use of this method of bone-plastic amputation ensures:

1. Creation of a long femoral stump, providing a large and functionally advantageous lever for controlling the prosthesis;

2. Formation of sufficient working space below the end of the stump, necessary for placing the flexion and rotation modules of the lower limb prosthesis, as well as their location at the same level as the contralateral knee joint;

3. The possibility of creating a stump designed for supporting the load on the end part, which ensures comfortable functional prosthetics without the need for the prosthesis socket to rest on the area of the ischial tuberosity and greater trochanter, discomfort due to the socket resting on the groin area when bending;

4. The possibility of early therapeutic-training and primary-final prosthetics due to optimal conditions and timing of the formation of femoro-patellar ankylosis.

Fig. 3 shows a diagram of fixation of the patella to the femoral bone sawing with two screws: A - amputation diagram (the bone sections to be removed are shaded), B - the part of the patella remaining after the sawing on the anterior flap is transferred to the femoral bone sawing (indicated by the arrow), C - holes for the screws are drilled with a drill at an acute angle of less than 90 degrees, G - the outer cortex of the patella is processed with a countersink for the screw heads, D - the patella is fixed with two screws.

In Fig. 3 the following notations are used:

1 - femur

2 - patella

3 - tibia

4 - drilled channels for screws

5 - countersunk holes for screw heads

6 - inserted cortical lag screws.

The improved method of transfemoral osteoplastic amputation is performed in five successive stages. The patient is positioned on his back, the limb to be amputated is exsanguinated with a pneumatic tourniquet. In the first stage (Fig. 3A), anterior (larger) and posterior flaps are cut out of the skin at the level of the knee joint. The patellar ligament is transected at the point of its attachment to the tibia. After incising the lateral walls of the upper recess, the anterior flap containing the patella is turned out with its inner surface forward. The cartilaginous surface of the patella is resected with an oscillating saw. Then, all tissues of the posterior surface of the knee joint are dissected with an amputation knife. The second stage (Fig. 3B) involves skeletonizing the distal metaepiphysis of the femur and performing its osteotomy at a distance of 8-10 cm proximal to the knee joint space so that its plane passes horizontally in the patient's standing position. For this purpose, in the frontal plane, the osteotomy is performed parallel to the supracondylar line so that the osteotomy plane coincides with the anatomical distal femorolateral angle, and in the sagittal plane is perpendicular to the anatomical axis of the femur. The patella together with the anterior flap is connected to the femoral cut and provisionally fixed with a Kirschner wire. The patellar ligament is sutured to the tendons of the posterior thigh muscles.

In the third stage (Fig. 3B), two through channels are formed through separate 0.5 cm long incisions above the patella with a 3.2 mm diameter drill in the direction as close as possible to the perpendicular from the plane of the femur osteotomy. The entrance holes of the channels are located on the anterior cortical plate of the patella, and the exit holes are on the lateral and medial cortical plates of the diaphyseal part of the femur.

The fourth stage involves widening the channels in the patella using a 4.3 mm diameter drill, and then using a countersink, creating recesses in its anterior cortical plate, intended for inserting the screw heads (Fig. 3G).

At the fifth stage, cortical screws are sequentially inserted, achieving interfragment compression and absolute stability (lag screw) (Fig. 3D). The operation ends with drainage and suturing of the stump wound.

An example of practical use of the method.

Patient G., 40, while on duty during the Special Military Operations, received a mine blast wound to the left leg with an extensive soft tissue defect and destruction of the tibial shaft over a length of 15 cm. Primary radiographs are shown in Fig. 4A. Upon admission to the Military Traumatology and Orthopedics Clinic at stage 3 of the Emergency Care Procedure, disarticulation was performed at the knee joint level (Fig. 4B). After stabilization of the patient's condition and normalization of hemodynamic parameters, osteoplastic supracondylar amputation of the femur was performed 2 weeks later using an improved method of fixing the patella with two screws (Fig. 4B). Two weeks after the operation, postoperative sutures were removed, the patient was examined by a prosthetics specialist, and measurements of the prosthesis socket were taken. A month after the operation, primary prosthetics was performed; the anatomical and functional result allowed the patient to become active and perform primary prosthetics earlier than with the classic Gritti-Shimanovski operation, in which prosthetics are possible no earlier than 3 months after amputation.

Eight patients were operated on using the developed method. All of them achieved satisfactory anatomical and functional results.

Claims (1)

A method of osteoplastic transfemoral amputation, characterized in that at the level of the knee joint, anterior and posterior flaps are cut from the skin, the patellar ligament is intersected at the point of its attachment to the tibia, after incising the lateral walls of the upper fold, the anterior flap containing the patella is turned with its inner surface forward, the cartilaginous surface of the patella is resected with an oscillating saw, then the tissues of the posterior surface of the knee joint are dissected with an amputation knife; then the distal metaepiphysis of the femur is skeletonized and its osteotomy is performed in such a way that its plane passes horizontally in the patient's standing position, while in the frontal plane the osteotomy is performed parallel to the supracondylar line so that the plane of the osteotomy coincides with the anatomical distal femorolateral angle, and in the sagittal plane it is perpendicular to the anatomical axis of the femur, and the level of the osteotomy of the femur is determined by the absence of corrugation of the soft tissues of the anterior surface of the thigh after test transposition of the patella onto the saw; then the patella is fixed to the femur file with two 4.5 mm diameter cortical lag screws with partial threads, which are inserted through channels drilled with 3.2 mm and 4.3 mm diameter drills, marked with a 4.5 mm tap in the patella and femur, in the patella-femur direction, with countersinking of the entry points on the patella under the screw head, then the patellar ligament is sutured with the tendons of the muscles of the posterior group of the thigh.