RU2345724C2 - Method of osteoplasty - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: resection of affected bones is performed during surgical processing of lesion focus. Removed at first stage of intervention - surgical processing - bone fragments are subjected to boiling for not less than 90 minutes. Removed bone fragments are sawed up longitudinally into cortical plates. By means of drill, in cortical plates holes are made. Through holes ligatures are passed and bunch of bone transplants is formed. Bone transplants are kept in solution of broad spectrum antibiotics. At second stage operational access is performed by making a cut outward from iliac bone spine. Bunch of bone transplants is placed into inter-muscular space between gluteus maximus muscle and gluteus medius muscle. Ends of ligatures, used to fix bone transplants, are dyed and sewn to iliac bone periosteum. Wound is sutured layer-by-layer. At third stage access on post-operational cicatrix, formed after second stage of operation, is carried out. Ligatures, on which bone transplants are fixed, are bared, moving along the latter by blunt way, bunch of bone plates is bared in muscular bed. Bone transplants are removed. Wound is sutured layer-by-layer hermetically. Osteoplasty is performed by means of obtained bone transplants.

EFFECT: approximately double shortening of terms of defect section replacement in osteoplasty, possibility to use bone tissue obtained in surgical processing for autotransplantation, elimination of causing additional injuries to patient.

1 ex

Description

The present invention can be applied to bone grafting of defects of limb bones formed during various pathologies: gunshot fractures, comminuted fractures, during operations with non-healing fractures, false joints, osteomyelitis.

It is known that the treatment of primary and secondary postognestral, especially large and giant bone defects of long limb bones is long, multi-stage and time-consuming, due to significant damage to biological tissues over the course, multicomponent gunshot wounds and purulent complications arising. Despite the tremendous success achieved in treating bone defects that occurred after peacetime injuries due to the widespread introduction of the method of extra focal transosseous osteosynthesis according to Ilizarov, the replacement periods for post-gestural bone defects remain long (1-5).

In order to reduce the maturation time of hypotrophic and atrophic bone regenerates, bone autoplasty with cortical-spongy grafts taken from the iliac wing is most often used, and non-salvage bone tissue after bone resection and sequestration is not used (6-9).

The basis for the use of free bone autoplasty, along with the already established traditional methods of transosseous osteosynthesis, were well-known clinical situations that arise during monolocal, bi- and multilocal osteosynthesis:

1) a sharp decrease in regenerative osteogenesis in the compression zone during bi- and multilocal osteosynthesis;

2) insufficient stimulation of osteogenesis during oncoming compression of the thinned ends of fragments;

3) the slow transformation of the fibula or its flakes after it is moved to the area of the defect of the tibia;

4) long terms of fusion at the junction of the tubular bone - spongy bone;

5) long-term immaturity of the distraction regenerate with a length of more than 6-8 cm, which requires additional osteotomy;

6) edge defects exceeding 1/2 the diameter of the bone diameter for more than 3 cm

We have developed and applied in the clinic the method of bone autoplasty with bone grafts after bone resection for chronic osteomyelitis, as well as free bone fragments that are not associated with surrounding soft tissues during primary, repeated and secondary surgical treatments. The method of bone grafting involves resection of the affected bones during the surgical treatment of the lesion, while the bone fragments removed during the first stage of the intervention - surgical treatment are boiled for at least 90 minutes, the removed bone fragments are cut longitudinally into cortical plates, holes are made in the cortical plates with a drill , pass through the holes of the ligature and form a bundle of bone grafts, then store the bone grafts in a wide range of antibiotic solution and the actions, by the second stage, provide surgical access, making an incision outside the iliac spine, place a bundle of bone grafts in the intermuscular space between the gluteus maximus and middle muscles, the ends of the ligatures with which the bone grafts are fixed, stain and suture the ilium to the periosteum, then suture in layers the wound, the third stage is accessed through the postoperative scar formed after the second stage of the operation, ligatures are exposed, on which bone grafts are fixed, blunt m by moving along the latter, is exposed ligament bone in muscle bed plates, bone grafts removed, the wound sutured by layers tightly, bone grafting is carried out using the obtained bone grafts.

The essence of the method is that the removed bone tissue is not disposed of, but is used for bone autoplasty. The scrap bone tissue is subjected to a special sterilization treatment, after which it is implanted into the muscles located outside the iliac wing for 2-4 months in order to prepare for subsequent bone grafting. In this case, bone grafts are partially subjected to resorption and revascularization from the surrounding muscles. Subsequently, prepared bone grafts are removed from the muscle bed and implanted in the area of hypotrophic or atrophic bone regenerate.

Resection of the affected bones and removal of bone fragments during the primary and secondary surgical treatments of the lesion was carried out according to generally accepted principles. The scrap bones were boiled for at least 90 minutes, then sawed lengthwise into cortical plates. Using a drill with a diameter of 1 mm, holes were made in cortical plates, a ligature was made through them, and a bundle of bone grafts was formed. Bone grafts were stored before the implantation of the latter into the muscles in a broad-spectrum antibiotic solution. Surgical access was performed from a cut of the skin, subcutaneous tissue and fascia 5-7 cm long outwards and parallel to the ilium spine. A bundle of bone grafts was implanted into the intermuscular space between the major and middle gluteal muscles, and the ends of the ligatures were stained with brilliant green and sutured to the periosteum of the ilium, then sutures were placed on the fascia of the subcutaneous tissue and skin.

The operation of bone autoplasty in the area of hypotrophic or atrophic regenerates was performed, as a rule, 2 or more months after implantation of the grafts into the muscles. By accessing the old postoperative scar formed after the second stage of the operation, ligatures were fixed on which bone grafts are fixed, and bluntly moving along the latter, exposed a ligament of bone plates in the muscle bed. Bone grafts were removed, the wound was sutured in layers tightly. In necessary cases, it is convenient to collect spongy bone grafts from the same access. Bone autoplasty in the area of hypotrophic or atrophic distraction regenerate was performed according to the generally accepted technique. In the overwhelming majority of cases, implanted cortical bone autografts were implanted at the junction of fragments into the central, least mineralized region of distraction regenerates, which was especially effective when the length of distraction regenerates exceeding more than 10 cm. Using free bone autoplasty in the region of immature bone regenerate allows cortical prepared autografts to be reduced. the ripening time is on average 1.5 times. Transplants in the form of bone plates are uniformly inserted into the longitudinal slit-like spaces made in a soft, longitudinally oriented regenerate, from one bone fragment to another over its entire thickness. The longitudinally oriented connective tissue of the regenerate reliably clamps spongy autografts in its thickness, after which layered sutures were applied to the wound.

In some cases, free bone grafting was used at the junction of the bone fragments. In this case, bone autografts in the form of “gravel” with sizes up to 1.0 × 1.5 cm and plates with dimensions of 0.3 × 1.0 × 3.5 cm were taken from the ilium from a typical access. The preparation of the autograft bed was carried out in such a way that scar tissue was removed from the area for future implantation. Bone plates were placed subperiosteally and intracortically overlapping bone fragments at the junction. In some cases, cortical-spongy grafts were driven into channels made with a drill of 5-6 mm from one fragment to another, connecting the joined bone fragments,

Also, to optimize the processes of osteoreparative repair, free bone grafting was used with scrap autografts with diastasis of 2-2.5 cm between bone fragments with the subsequent convergence of the ends of the fragments until they are completely in contact. At the same time, part of the grafts was implanted into the bone marrow cavity, while the other part of the grafts, when the bone fragments were compressed, surrounded the joint area with a kind of sleeve.

Clinical example. Wounded S., 25 years old, on September 25, 2000, during a counter-terrorist operation in Chechnya, he received a multiple gunshot fragmentation-wound wound to the right lower limb: a gunshot comminuted fracture of the diaphysis of the right femur in the lower third with displacement of fragments, a gunshot comminuted fragmentary fracture of the tibia in middle and lower third with a primary bone-bone soft-tissue defect, gunshot comminuted fracture of the fibula in the middle third with displacement of fragments, neuropathy of the fibula moat with severe motor, sensory and trophic disorders. At the stages of medical evacuation, primary and repeated surgical treatment of wounds and stabilization of the fragments with the Ilizarov apparatus were performed. The wound process was complicated by chronic osteomyelitis of fragments of the tibia, the wounds on the thigh healed by secondary intention. 11/15/03 delivered by air to the State Military Command named after NN Burdenko from 1603 OVG Rostov. On admission, a bone-soft tissue defect was detected clinically and radiologically in the middle third of the right lower leg, and the bone defect of the tibia was 15 cm, while the bone necrotic fragment of the distal fragment, which was not covered by soft tissues, stood in the wound for 5 cm, profuse purulent discharge with a pseudomonas smell. In the soft tissues at the fracture level, bone densities of high density were X-ray visualized. 11/16/03. operated - surgical treatment of the wound was performed with removal of sequesters, resection of the distal fragment of the tibia over 3 cm, necrectomy of soft tissues, non-free skin grafting with oncoming triangular flaps, which made it possible to cover the exposed bone with soft tissues. Recycled bone tissue after removal of sequestration and resection of the tibia was prepared and preserved in a solution of antibiotics. In the postoperative period, flow-aspiration drainage of the postoperative wound with antibiotic solutions was performed for 15 days. The osteomyelitis process was stopped. 12/05/03 reoperated - reassembly of the CDA, osteotomy of the tibia in the upper third, implantation of scrap bone grafts in a ligament on the ligature into the intermuscular space between the gluteus maximus and gluteus maximus muscles. Postoperative wounds healed by first intention. After 8 days, distraction of the osteotomized fragment in the upper third of the leg and distraction of a bone fragment of 6 cm in length along the fragmentary fracture line towards each other 1 mm per day in 4 doses was started. The remaining soft tissue defect 10 × 5 cm after performing non-free skin grafting was replaced as the bone fragments were distracted and joined. The maturation of the distal distraction regenerate was slow, with the formation of intraosseous cysts and thinning like an hourglass. The duration of distillation was 98 days. Given the formation of hypotrophic bone distraction regenerate in the lower third, it was decided to perform bone autoplasty with scrap bone tissue, as well as bone autoplasty of the junction of bone fragments with cortical-spongy bone autografts, taken from the wing of the left ilium. 05/15/04 operated on - access to the old postoperative scar prepared bone autografts were extracted from the muscle sleeve. Two cortical-spongy grafts from the iliac crest 4 · 1 · 1 cm in size were taken from the same access. Of the three separate accesses 2–2.5 cm long, the area of distraction regenerate in the lower third of the leg was exposed. Cortical plates are introduced into the regenerate along the fibers in the region of the thinned regenerate, as well as in the region of bone cysts. Layered seam of wounds. At the junction of the bone fragments, channels with a diameter of 8 mm were drilled from two accesses of 1.0 cm in diameter, passing through both joined fragments, into which bone autografts were tightly hammered with impaction. The postoperative course is smooth, the wounds healed by primary intention. Repeatedly carried out rehabilitation treatment in the conditions of 6 CVKG. Subsequently, a distinct positive dynamics was noted until bone regenerates fully matured and consolidation at the junction of bone fragments and a gunshot fracture of the femur. The device was dismantled on 12/15/04. Fully restored supportability of the limb. By the decision of the VVK, he was declared fit for military service with minor restrictions.

Thus, within 12 months, the replacement of the tibial defect over 18 cm and the fusion of the gunshot fracture of the femur were achieved, which exceeds the average statistical treatment time by half, which confirms the effectiveness of the proposed method of bone autoplasty with scrap bone tissue.

Bibliography

1. Ilizarov G.A. Some theoretical and clinical aspects of transosseous osteosynthesis from the perspective of general biological patterns that we discovered. // Experimental-theoretical. and clinic. aspects of transosseous. osteosynthesis developed at KNIIEKOT: Abstracts. doc. Intl. conf. - Kurgan, 1986.- p. 7-12.

2. Ilizarov G.A., Iryanov Yu.M., Petrovskaya N.V. Ultrastructural features of osteogenesis in the distraction diastasis of elongated bone. // Experimental-theoretical. and clinic. aspects of transosseous osteosynthesis developed at KNIIEKOT: Abstracts. doc. International Conf. - Kurgan, 1986 .-- p.24-25.

3. Ilizarov G. A. Possibilities of treating false joints and defects of long tubular bones according to our method. // V All-Union. Congress of Orthopedic Traumatologists (Odessa, September 22-24, 1988): Abstracts. doc. - M., 1988. - Part II. - p. 28-30.

4. Masimov Majid Oruj-oglu. Surgical tactics and reconstructive surgery in the prevention and treatment of purulent-necrotic complications and consequences of severe gunshot injuries of the extremities: Abstract. dis. ... doctor. honey. Sciences, Yaroslavl, 2006, 32 p.

5. Makushin V.D., Kuftyrev L.M. Therapeutic and rehabilitation benefits of the Ilizarov method for pseudoarthrosis and hip defects. // Transcost. Compress. and distrac. osteosynthesis in orthopedics and traumatology: (Theme. Collection of scientific works). - Kurgan, 1980 .-- Issue 6. p. 12-18.

6. Movchan A.S. Bone grafting of false joints and defects of long bones with blood-supplying transplants: Abstract. Dis. ... doctor. honey. Sciences, Riga, 1991, 31 p.

7. Novachenko N.P. The formation of bone regenerate to replace the proximal end of the thigh, destroyed by gunshot damage // Orthopedist., Traumatol. - 1955. - No. 5. - p. 15-21.

8. Oganesyan OV Basics of external transosseous fixation. - M., 2004.

9. Chaklin V.D. Pseudoarthrosis and bone defects // Orthopedist., Traumatol. - 1973. - N 3.p. 1-9.

Claims (1)

The method of bone grafting, including resection of the affected bones during surgical treatment of the lesion, characterized in that the bone fragments removed at the first stage of the intervention - surgical treatment - are boiled for at least 90 minutes, sawed off the removed bone fragments longitudinally into cortical plates, using a drill holes in the cortical plates are passed through the ligature holes and a ligament of bone grafts is formed, then the bone grafts are stored in a solution of antibiotics Of a wide spectrum of action, the second step is surgical access, making an incision outside the iliac spine, a bundle of bone grafts is placed in the intermuscular space between the gluteus maximus and middle muscles, the ends of the ligatures that fix bone grafts are fixed, stained and sutured to the periosteum of the ilium, then in layers the wound is sutured, the third stage is accessed through the postoperative scar formed after the second stage of the operation, ligatures are exposed, on which bone trans the implants, bluntly advancing along the latter, expose the ligament of bone plates in the muscle bed, the bone grafts are removed, the wound is sutured in layers tightly, bone grafting is performed using the obtained bone grafts.