RU2303414C2 - Method for operative treatment of multicomminuted fractures and fractures-dislocations of ankle bone - Google Patents

Abstract

FIELD: medicine, traumatology, orthopedics.

SUBSTANCE: it is necessary to remove the fragments of ankle bone, fulfill arthrodesis between tibia and heel bone along with osseous autoplasty out of resected fibula and temporal fixation with the needles for the period of applying the apparatus of external fixation. The latter should be applied onto the foot and the shin followed by tibial osteotomy. Simultaneously one should carry out microdistraction between tibial fragments and microcompression between tibia and heel bone. The innovation provides the reconstruction of support capacity and limb's length, improves limb's circulation and shortens the terms of therapy.

EFFECT: higher efficiency of therapy.

8 dwg, 1 ex

Description

The invention relates to medicine, in particular to traumatology and orthopedics.

Multi-fragmented fractures of the talus and its chronic fractures are severe injuries and, when trying to save the talus by any means, the treatment ends with the development of aseptic necrosis of the fragments, which leads to the formation of deforming arthrosis of the ankle and subtalar joints, pain, limitation of joint function, trophic disturbances, loss of foot support .

With this pathology, De Palma (cited by V.D. Chaklin, "Fundamentals of Operative Orthopedics and Traumatology", Moscow, 1964, pp. 689-691) proposed a radical operation to remove fragments of the talus and perform arthrodesis between the tibia and calcaneus using autoplastics from the resected distal end of the fibula.

The operation ends with the establishment of the foot in relation to the tibia at an angle of 100-110 ° and fixation with a circular plaster cast from the fingertips to the middle of the thigh for a period of 3-4 months, and if necessary, longer. It is when applying a plaster cast that the fragments can be displaced in width and at an angle. After removing the plaster cast, X-ray control is performed to determine the adhesion between the fragments and the tactics of further treatment.

The described operation is accepted by us as a prototype.

Assessing the postoperative period and the result of such an operation, it should be recognized that the fusion between the tibia and calcaneus, that is, the formation of ankylosis, is achieved at the cost of shortening the limb to the height of the lost talus and the removed articular surfaces of the arthrodesis bones. In this case, the patient must wear orthopedic shoes for life. After removing the plaster cast after 3-4 months, there is always contracture of the knee joint, hypotrophy and hypotension of the muscles of the thigh and lower leg, osteoporosis develops, which requires a long rehabilitation treatment. Visually, which is important for women, a cosmetic defect is determined - shortening the length of the lower leg and increasing its circumference in the lower third due to excess soft tissue during shortening of the lower leg. During treatment in a cast, it is impossible to correct the angle between the foot and lower leg if necessary; evaluate the degree of fusion between the calcaneus and the talus.

The authors of the application also propose to perform an arthrodesis operation between the tibia and calcaneus using an autograft from the fibula, but with temporary fixation by their knitting needles for the period of application of the external fixation apparatus on the foot and lower leg. In the apparatus, an osteotomy of the tibia is performed (figure 2).

In the postoperative period, according to the method of G.A. Ilizarov, microdistraction between fragments of the tibia is performed in order to grow bone regenerate to compensate for the shortening of the foot and supporting microcompression between the calcaneus and tibia to create optimal conditions during the formation of ankylosis between them (Fig. 3).

The entire treatment period in the apparatus provides for the possibility of movements in the knee joint. Exercise a metered load on the foot.

In the presence of radiological and clinical signs of ankylosis between the tibia and calcaneus and the elongation of the lower leg to the height of the lost talus is achieved, the apparatus is dismantled (Figs. 4, 5, 6).

The advantages in the proposed method are obvious:

- the operation of the arthrodesis between the tibia and calcaneus, as well as the osteotomy of the tibia in the external fixation apparatus is carried out simultaneously;

- the process of the formation of ankylosis between the calcaneus and tibia and lengthening of the lower leg occurs simultaneously, which reduces the total duration of treatment of the patient.

- during treatment, it is possible to carry out X-ray monitoring, which allows to evaluate the process of osteogenesis, to regulate the rate of elongation of the lower leg, to correct, if necessary, the angle between the foot and lower leg;

- due to the lengthening of the tibia, the muscles of the leg are stretched and its circumference acquires the same form,

- the entire period of treatment in the external fixation apparatus involves a metered load on the foot and movements in the knee joint, which improves blood circulation of the limb, prevents the development of osteoporosis and contracture in the knee joint, hypotension and hypotrophy of the muscles of the thigh and lower leg;

- after removal of the apparatus, special rehabilitation treatment and wearing orthopedic shoes are not required to compensate for the shortening of the lower leg.

Clinical example

Patient Selezneva I.V., 42 years old, was admitted to the institute with a diagnosis of aseptic necrosis of the left talus (Fig. 1), which arose after a timely unresolved fracture of the talus bone fragments.

Due to the loss of support ability and dysfunction of the left foot, constant swelling and pain in the ankle joint, the patient underwent a simultaneous operation to remove fragments of the talus, arthrodesis between the tibia and calcaneus with autoplasty from the outer ankle of the fibula with temporary fixation on their knitting needles external fixation apparatus on the bones of the foot and lower leg.

An osteotomy of the tibia was performed in the apparatus for microdistraction between its fragments in order to grow bone regenerate to the height of the lost talus. After 5 months, with repeated hospitalization, the patient walks with a cane at full load (Figs. 7, 8). On the control x-ray revealed ankylosis between the tibia and calcaneus. Part of the device from the foot removed. The patient was discharged with a recommendation to continue the load on the operated limb and microdistraction between the fragments of the tibia. After 8 months, X-ray examination revealed a bone regenerate 3.5 cm high between the fragments of the tibia.

A clinical test was performed (relaxation of the rods between the rings), confirming the fusion of the tibia after its lengthening. The device is removed. The support ability of the operated limb was restored without the need for special rehabilitation treatment. Wearing an orthopedic insole is recommended.

Claims (1)

A method for the surgical treatment of multi-fragmented fractures and fractures of the talus, including the removal of fragments of the talus, performing arthrodesis between the tibia and calcaneus with autoplasty of the resected fibula and temporarily fixing them with knitting needles for the period of application of the external fixation apparatus, characterized in that impose an external fixation device, after which an osteotomy of the tibia is performed, microdistraction between fragments of the tibia is simultaneously performed th bones and mikrokompressiyu between the tibia and the calcaneus.

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