WO2019035734A1 - Method for surgical treatment of pubic rami pelvic fractures - Google Patents

Abstract

The invention relates to traumatology and orthopaedics and can be used in surgical treatment of pubic rami pelvic fractures by closed intraosseous osteosynthesis. Means of bone fixation are inserted intraosseously, said means being configured as an elongated rod with a circular cross section, which comprises two portions: a round-topped proximal elongated portion of a smaller diameter and a distal portion of a bigger diameter fixed in a guiding setting apparatus to a post by an internal screw thread and configured with two through openings transverse to the axis of the distal portion, wherein the axes of the proximal and distal portions of the means of bone fixation are at an angle of 150-170° arranged with respect to each other in the longitudinal plane perpendicular to the axis plane of the openings in the distal portion of the means of bone fixation. The method makes it possible to reduce injuries and shorten the recovery period.

Description

 METHOD OF SURGICAL TREATMENT OF FRACTURES OF LONA BONES

 Pelvis

Technical field

The invention relates to the field of medicine, namely to traumatology and orthopedics during surgical treatment for closed internal fixation of traumatic fractures of the pelvic bones of the pelvis.

Prior art

There is a method of surgical treatment of fractures of the pelvic bones of the pelvis with a closed intraosseous osteosynthesis. The patient is placed on his back on an X-ray transparent operating table with a roller under the knee joints in the flexion position, bladder catheterization is performed, and the surgical field is treated with a sterile antiseptic underwear, prepare an electron-optical converter (EOC) for the entire operation, then perform a surgical approach, By means of which, on the side of the intact pelvic half, intra bone fixation means are introduced for fixation of bones, which is detachably fixed in a guide of a mounting device made of a horizontal jig and a stand that is detachably connected to it, with two through holes in the jig having parallel axes parallel to the rack with the distance between them equal to the distance between the holes coaxial to them in the means for fixing the bones in a position fixed on the guide mounting device, and these holes are the conductor is made with the possibility of alternately installing them removable tubular adapter with flanging adapter, while the outer diameter of the adapter is equal to the diameter of these holes, which is equal to the diameter of the head of the fixing screw, and the inner diameter of the adapter is equal to the diameter of the drill for the last seat, then make a skin incision in the area the intended installation of the guide for fixing screws, then through a removable tubular adapter, which is alternately inserted into one of the two holes Steas in the conductor, drill to perform the formation of holes in the bone, then remove the drill and detachable adapter successively and block the means of fixing the bones with self-cutting fixing screws, then perform the final intraoperative x-ray control of the position of the fixation of bones relative to the anterior half of the pelvis, then the fixation means of the bones are released from the guide wiper surgical wounds and aseptic sticker on the seams (patent RU2572189, IPC AV 17/90. Published on 12/27/2015, BKXTC.N ° 3 6).

 This technical solution is inherent in the set of features that are closest to the set of essential features of the invention, it has a purpose that coincides with the purpose of the invention and is the closest to the achieved result, therefore, it is taken as a prototype.

 The disadvantage of the prototype is the limited use in the treatment of extended fractures, a long process of recovery due to increased trauma.

DISCLOSURE OF INVENTION

The technical result from the use of the invention is to expand the treatment of extended fractures, reducing the time of the recovery process and reduced invasiveness.

 Below are the general and particular essential features that characterize the causal relationship of the claimed solution to the specified technical result based on the prior art.

The method of surgical treatment of fractures of the pelvic bone bones is that the patient is placed on his back on the X-ray transparent operating table with a roller under the knee joints in the flexion position. Catheterization of the bladder is performed, the surgical field is treated with a skin antiseptic, which is limited to sterile underwear. Electron-optical converter (EPO) is prepared for the entire operation period. A surgical approach is performed, through which, from the intact half of the pelvis, an intra-bone bone fixation device is inserted, detachably secured in a guiding mounting device made of a horizontal conductor and a stand detachably connected to it. The conductor has two through holes with parallel axes parallel to the rack with a distance between them equal to the distance between the holes coaxial to them in the means for fixing the bones in a position fixed on the guide mounting device. These holes in the conductor is made with the possibility of alternately installing them removable tubular adapter with flanging adapter. The outer diameter of the adapter is equal to the diameter of these holes, which is equal to the diameter of the head of the fixing screw, and the inner diameter of the adapter is equal to the diameter of the drill for the seat of the fixing screw. Then, a skin incision is performed in the region of the intended installation of the guide for fixing screws, then through a removable tubular adapter, which is alternately inserted into one of the two holes in the jig, the holes in the bone are formed with a drill. Next, the drill and the removable adapter are subsequently removed and the means for fixing the bones are locked with self-tapping fixing screws. Then perform the final intraoperative x-ray control of the position of the means of fixation of the bones relative to the anterior half of the pelvis. Next, the means of fixation of the bones are released from the guiding installation device and the latter is removed from the surgical wound. Stitches on surgical wounds and aseptic stitching. In this case, the patient is placed in the position of flexion of the legs at the knee joints of 150-170 °, and the surgical approach is performed in the form of a skin puncture 1 cm long in the middle of the pubic symphysis. Then, with the end of the scalpel, the anterior upper angle of the body of the pubic bone in the region of the medial edge of the pubic tubercle immediately below the pubic crest. After that, a cylindrical defender of soft tissues under the control of an image intensifier in the inlet and outlet projections conducts a guide needle with a diameter of 2.0 mm through the upper corner of the body of the pubic bone along its upper branch intracutaneously, ensuring the perforation of the second cortical wall is preserved. After that, along the guide needle, the anterior cortical wall of the pubic bone is drilled out with a cannulated drill with a diameter of 6 mm, and then the needle and drill are removed. Next, through the surgical access from the intact half of the pelvis, a bone fixation device is introduced intraoscially, made as an elongated round rod of two parts, proximal with a rounded end of a smaller diameter part and a distal part of a larger diameter fixed in the guide mounting device to the stand by internal thread and made with two through transverse its axis holes. When this axis is proximal and The distal portions of the bone fixation device are located at an angle of 150-170 ° to each other in the longitudinal plane perpendicular to the plane of the axes of the holes in the distal part of the bone fixation device, which are pushed inside the pubic bone until its proximal part is completely submerged in the bone canal along the inlet view. Next, perform the specified skin incision of the anterior abdominal wall for fixing screws in the form of a puncture length of 1 cm, then through a removable adapter inserted alternately into one of two holes that are placed along the axis of the conductor guide mounting device, these holes are formed with a diameter of 2.5 mm in the bone at a given angle of 90 ° relative to the means of fixing the bones. After removing the drill and detachable adapter, the means for fixing the bones are blocked by two self-tapping fixing screws with a diameter of 3.5 mm and a length excluding the penetration of the said fixing screws beyond the body of the pubic bone. Then, after the final intraoperative x-ray control of the position of the fixation of the bones relative to the anterior semiring of the pelvis, the fixation fixture is disconnected from the guide installation device, which is removed from the surgical wound, stitched to the surgical wound, and an aseptic sticker is applied to them.

Blueprints

The implementation of the method of surgical treatment according to the invention is illustrated in the drawings, where: in figure 1 the installation of the guide spokes; figure 2 - drilling cannulated drill; on fig.Z - the introduction of a means of fixation; figure 4 - preparation for fixing the fixation means; figure 5 is a fixed means of fixation; figure 6 - guiding installation device; 7 - shows a jig with a partial cut; on Fig - fixation tool, side view; in fig. 9 - formation of surgical access to the pubis (photo); figure 10 - installation of the guide spokes in the distal fragments of the pubic bone (photo); in Fig.1 1 - installation of the guide spokes in the distal fragment of the pubic bone under the control of the EOP (outlet view) (X-ray); on Fig - installation guide needles in the distal fragment of the pubic bone under the control of the EOP (inlet view) (x-ray); on Fig - reaming cortical plate cannulated drill on the guide needle (photo); on Fig - reaming cortical plate cannulated drill on the guide needle under the control of the image intensifier (outlet view) (x-ray); on Fig - means for fixing the bones in the guide installation device (photo); on Fig - intraosseous holding the pin in from the distal to the proximal fragments of the pubic bone (x-ray); on Fig - skin incision of the anterior abdominal wall for fixing screws (photo); on Fig - the formation of the channel in the distal fragment of the pubic bone drill with a diameter of 2.5 mm to lock the pin with screws (photo); on Fig - locking pin with a self-tapping screw with a diameter of 3.5 mm (x-ray); on Fig - install the locking screw with a screwdriver through the guide device (photo); on Fig - the final locking of the pin with two self-tapping screws with a diameter of 3.5 mm (x-ray); on Fig - the final control under the image intensifier after fixation of the fracture of the pubic bone fixation means (x-ray); on Fig - view of the surgical field after suturing surgical approaches (photo).

 An embodiment of the invention

The method of surgical treatment of fractures of 1 pubic bones of 2 pelvis 3 is that patient 4 is placed on its back on an X-ray transparent operating table with a roller under the knee joints in the flexion position.

 Catheterization of the bladder is performed, the surgical field is treated with a skin antiseptic, which is limited to sterile underwear.

 Electron-optical converter (EPO) is prepared for the entire operation period.

 Perform surgical access 5 (Fig.9), through which from the side of the intact half of the pelvis 3 intra-bone injection means fixing 6 bones 2, detachably fixed in the guide installation device 7, made of a horizontal jig 8 and a rack 9, detachably connected to it.

 In the conductor 8 there are two through holes 10 with parallel axes parallel to the rack 9 with a distance S between them equal to the distance L between the holes coaxial to them 1 1 in the means for fixing the bones 6 in position fixed to the guide mounting device 7.

These holes 10 in the conductor 8 is made with the possibility of sequential installation of a removable tubular adapter 12 with flanging 13. The outer diameter of the adapter 12 is equal to the diameter of these holes 10 in the conductor 8.

 The diameter of these holes 10 is equal to the diameter of the head of the fixing screw 14, and the inner diameter of the adapter 12 is equal to the diameter of the drill 15 for the seat of the fixing screw 14.

 Then perform a skin incision 17 in the area of the intended installation of the sender 16 for the fixing screws 14.

 After that, through a removable tubular adapter 12, which is alternately inserted into one of the two holes 10 in the jig 8, the drill 15 performs the formation of holes in the bone 2.

 Next, the drill bit 15 and the removable adapter 1 1 are successively removed and the fixation means for fixing 5 bones with self-tapping fixing screws 14 are produced.

 Then perform the final intraoperative x-ray control of the position of the fixation device of 6 bones 2 relative to the anterior half of the pelvis 3.

 Further, the fixation means 6 bones 2 are released from the guiding installation device 7 and the latter is removed from the surgical wound.

 At the same time, patient 4 is laid in the position of flexion of the legs in the knee joints of 150-170 °, and surgical access is carried out in the form of a skin puncture with a length of 1 cm (FIG. 9) in the region of the middle of the pubic joint.

 Then, with the end of the scalpel, the anterior upper angle of the body of the pubis 2 in the region of the medial edge of the pubic tubercle immediately below the pubic crest.

 After that, a cylindrical defender of soft tissues under the control of an image intensifier in the inlet and outlet projections conducts a guide needle 18 with a diameter of 2.0 mm through the upper corner of the body of the pubic bone 2 along its upper branch intracutaneously (figure 10, figure 1 1, figure 12) with preservation of perforation of the second cortical wall.

 After that, along the guide needle 18, the anterior cortical wall of the pubic bone is drilled with a cannulated drill 19 with a diameter of 6 mm (FIG. 13, FIG. 14), and then the needle 18 and the drill 19 are removed.

Next, through the surgical access (FIG. 15, FIG. 16), from the side of the intact half of the pelvis 3, the means for fixing 6 bones 2 is made intraosseously, made in the form of an elongated round-section rod of two parts, the proximal part 20 of a smaller diameter and distal part 21 larger diameter, fixed in the guide installation the device 7 to the rack 9 by means of an internal thread and holes 1 1 made with two through transverse axes thereof.

 In this case, the axes of the proximal 20 and di steel 21 parts of the fixation device 6 of the bones 2 are located at an angle of 150-170 ° to each other (Fig. 8) in the longitudinal plane perpendicular to the plane of the axes of the holes 1 1 in the distal part 21 of the fixation device 6 of the bones 2, which is advanced inside the pubis to the full immersion of its proximal part 20 in the bone canal along the inlet view.

 Next, perform the specified skin incision 17 of the anterior abdominal wall (Fig. 17) for the fixing screws 14 in the form of a puncture length of 1 cm.

 Then through a removable adapter 12, inserted alternately into one of two holes 10, which are placed along the axis of the conductor 8 of the guide installation device 7, these holes are formed with a diameter of 2.5 mm in bone 2 (FIG. 18, FIG. 19) at a predetermined angle 90 ° relative to the fixation means 6 bones 2.

 After removing the drill 15 and the removable adapter 12, the fixing means 6 of the bones 2 (FIG. 20, FIG. 21) are blocked by two self-cutting locking screws 14 with a diameter of 3.5 mm and a length excluding the penetration of the said locking screws 14 beyond the body of the pubic bone 2.

 Then, after the final intraoperative x-ray control of the position of the fixation device 6 of the bones 2 (FIG. 22) relative to the anterior half-ring of the pelvis 3, the fixation means 6 are disconnected from the guiding installation device 7, which is removed from the surgical wound, stitched to the surgical wound (FIG. 23) and carry out an aseptic sticker on them.

 Comparison of the claimed technical solution with the state of the art known from scientific, technical and patent documentation as of the priority date in the main and adjacent headings did not reveal a means inherent in signs identical to all features contained in the claims of the invention proposed by the applicant, including the characteristics of the assignment.

 That is, the set of essential features of the claimed solution was not previously known and is not identical to any known technical solutions, therefore, it meets the condition of patentability "novelty."

Analysis of the known technical solutions in this field of technology has shown that the proposed technical solution does not follow to a specialist in the obvious way from the prior art, since no solutions have been found that have signs consistent with its distinctive features, or such decisions have been identified, but the fame of the influence of the distinctive features on the technical result indicated in the application materials has not been confirmed.

 Those. The claimed solution has features that are not available in the known technical solutions, and the use of these features in the claimed essential features set makes it possible to obtain a new technical result — expanding the treatment options for extended fractures, shortening the recovery process, and reducing trauma.

 Consequently, the proposed technical solution can be obtained only through a creative approach and it is not obvious to an average specialist in this field, i.e. has an inventive step compared with the existing level of technology.

Industrial Applicability

This technical solution is industrially applicable, since in the description of the application and the name of the invention its purpose is indicated, it can be carried out industrially for closed internal fixation in case of traumatic fractures of the pelvic pluminal bones.

 The invention is feasible and reproducible, and the distinctive features given in the claims are significant because they affect the possibility of solving the technical problem indicated in the application and obtaining the technical result provided by the invention, that is, they are in causal connection with the specified result and therefore are significant.

 The invention, as described in each of the claims, can be carried out using the means and methods described in patent RU2572189, which has become publicly available before the priority date of the invention.

 In addition, the implementation of the claimed invention is achieved by the implementation of the specified destination.

Therefore, the claimed technical solution meets the condition of patentability "industrial applicability", which is also illustrated by the following clinical example of the implementation of this method of treatment, confirming the possibility of obtaining the claimed technical result. The practical implementation of the proposed method is illustrated by illustrations shown in FIG. 9 - FIG. 23, which show the surgical treatment by closed internal fixation in case of traumatic fractures of the pelvic bones.

 The implementation of the claimed invention is achieved by the implementation of the specified destination, as evidenced by the following clinical example, showing the possibility of obtaining the claimed technical result.

 Patient F. 47 years old was admitted to the hospital with a fracture of the pubic bones obtained in an accident on the railway.

 After preoperative planning, the surgical technique was performed by the claimed method.

 The position of the patient 4 on the back on the X-ray transparent operating table with a roller under the knee joints in the position of flexion.

 Under conditions of combined anesthesia, in order to control diuresis and intraoperative monitoring of bladder injuries, a bladder catheter was made using a Foley catheter.

 The surgical field was processed with a three-fold skin antiseptic from the middle third of the thighs to the rib arches. The surgical field is limited to sterile laundry.

 For intraoperative x-ray control, an electron-optical converter (hereinafter referred to as EOC) was used.

 The end of the scalpel made a surgical approach (skin puncture) 5 with a length of 1 cm in the region of the middle of the pubic symphysis (Fig.9), while reaching the anterior upper angle of the body of the pubic bone 2 in the region of the medial edge of the pubic tubercle (tuberculum pubicum) immediately below the pubic crest (crista pubica).

 The operating surgeon is located on the opposite side of the fracture of the pubic bone 2.

 Through a cylindrical soft tissue protector, a guide pin 18 with a diameter of 2.0 mm (figure 10) is drawn through the upper corner of the body of the pubic bone along its upper branch intraosteously avoiding perforation of the second cortical wall (figure 1, figure 12).

 Along the guide needle 18, the anterior cortical wall of the pubic bone was drilled with a cannulated drill 19 with a diameter of 6 mm (FIG. 13).

Through the surgical access 5 from the side of the intact pelvic half, a means of fixing 6 bones 2, fixed in the guide of the adjusting device 7, was introduced intraosseously (Fig. 16). Using the guide of the adjusting device 7, the fixation device of the bones 6 is advanced inside the pubic bone until the proximal part of the fixation device in the bone channel is completely submerged along the inlet view.

 Made a skin incision (puncture) 17 of the anterior abdominal wall with a length of 1 cm in the area of the intended installation guide for fixing screws 14.

 Then through the removable guide 12, inserted alternately into one of the two holes 10 of the conductor 8, the holes in the bone are formed through a removable guide inserted into the same guide of the guide of the adjusting device with a drill of 2.5 mm diameter at a given angle of 90 ° relative to the means of fixing the bones ( 18).

 After removing the drill 15 and the removable guide 12, the locking means of the bones are locked with two self-tapping fixing screws 14 with a diameter of 3.5 mm of the corresponding length (Fig. 19).

 The use of two fixing screws 14 eliminates the migration of the fixation means 6 for the bones inside the bone canal and its rotation around the axis (FIG. 20, FIG. 21).

 The final intraoperative X-ray control of the position of the fixation means 6 bones 2 relative to the anterior half of the pelvis was performed, which prevents penetration of fixing screws 14 through the proximal part of the fixation bones 6 into the pelvic cavity (Fig.22).

 Stitches are put on the surgical wounds (Fig. 23). Aseptic stitching is performed.

 After treatment, the patient was able to move on crutches.

The example confirms the possibility of implementing the claimed set of essential features of the claims of the method of surgical treatment of fractures of the pelvic bone bones by closed intraosseous osteosynthesis with the achievement of the claimed technical result - the expansion of treatment of extended fractures, reduction of the recovery process and reducing the trauma of surgery.

 The proposed method operated 10 patients with good results, and in some cases, patients were able to stand up and walk with crutches the next day after surgery.

Strong fixation of the pubic bones and their connection to each other by means of fixation 6, fixed in the bone 2 by fixing screws 14 s the ability to maintain micromotation in the region of the pubic articulation and provides physiological fixation by maintaining the depreciation function of the posterior pelvic, and also creates physiological conditions for the restoration of the pubic bones while shortening the rehabilitation time.

 The use of the invention allows to expand the treatment of extended fractures, reduce the time of the recovery process and reduce the invasiveness of surgical intervention.

 In addition, the operation is accompanied by minimal risks of intraoperative and postoperative complications and a good functional and cosmetic result (Fig. 23).

Claims

Claim The method of surgical treatment of fractures of the pelvic bones of the pelvis with a closed intraosseous osteosynthesis is that the patient is placed on his back on an X-ray transparent operating table with a roller under the knee joints in the flexion position, the bladder is catheterized, the surgical antiseptic is treated and sterile underwear is processed , prepare the electro-optical transducer for the entire period of the operation, then perform surgical access, through which the sides of the intact pelvic half intracutaneously inject a means of fixation of the bones, detachably fixed in a guide mounting device made of a horizontal conductor and a stand detachably connected to it, while the conductor has two through holes with parallel axes parallel to the rack with a distance between them equal to the distance between coaxial holes with them in the means of fixation of the bones in a position fixed on the guide mounting device, and these holes in the conductor are With the possibility of alternately installing a removable tubular adapter with flared adapter, the outer diameter of the adapter is equal to the diameter of these holes, which is equal to the diameter of the head of the fixing screw, and the inner diameter of the adapter is equal to the diameter of the drill for the fixing screw seat, then make a skin incision in the area the intended installation of the guide for the locking screws, then through a removable tubular adapter, which is alternately inserted into one of the two holes in the box the drill, with the drill, perform the formation of holes in the bone, then remove the drill and the detachable adapter and block the means for fixing the bones with self-cutting fixing screws, then perform the final intraoperative x-ray control of the position of the fixation of bones relative to the anterior half of the pelvis and the latter is removed from the surgical wound, stitched to the surgical wound and aseptic to watering on joints, characterized in that the patient's feet are placed in a position of flexion in the knee joints, the surgical access operate as a skin puncture one centimeter in mid symphysis pubis, and then reaches the front end of the scalpel the upper corner of the body of the pubis in the medial edge of the pubic tubercle immediately under the pubic crest, then through a cylindrical defender of soft tissues under the control of the image intensifier in the inlet and outlet projections conduct a guide needle with a diameter of two millimeters through the upper corner of the body of the pubic bone along its upper branch preservation of the perforation of the second cortical wall, then, along the guide needle, the anterior cortical wall of the pubic bone is drilled with a cannulated drill with a diameter of six milliliters the ester, and then the needle and drill are taken out, then through the surgical access from the intact half of the pelvis, intraocularly introduces a means of fixing the bones, made as an elongated round rod of two parts, proximal to the smaller diameter and distal part of the larger diameter, fixed in the guide mounting device to the rack by means of internal thread and made with two holes through its transverse axis, with the proximal and di The steel parts of the bone fixation device are arranged at an angle of 150-170 ° to each other in the longitudinal plane perpendicular to the axis of the axes of the holes in the distal part of the bone fixation tool, which are pushed inside the pubic bone until the proximal part is completely submerged in the bone canal along the inlet view, then specified skin incision of the anterior abdominal wall for blocking screws in the form of a puncture one centimeter long, then through a removable adapter inserted alternately into one of two holes that are placed along the axis the conductor guide installation device, form these holes in the bone with a diameter of two and a half millimeters at a predetermined angle of 90 ° relative to the means of fixing the bones, then, after removing the drill and the removable adapter block the means of fixing the bones with two self-cutting fixing screws, excluding the penetration of the said fixing screws beyond the body of the pubis, then after the final intraoperative x-ray control of the position of the means of fixation of the bones relative to the anterior half of the pelvis, the fixation device is disconnected from the guide of the installation device, which is removed from the surgical wound, stitched to the surgical wound and an aseptic sticker on them.