RU2421170C1 - Method of treating subtotal cystic formations or tumour-like diseases of tubular bones - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to orthopedics. Osteotomy of bone of the section between healthy and degenerated bone tissue is carried out. Resection of pathologic focus is performed. Into diastasis, created between bone fragments after tumour resection, cortical allotransplant is introduced. Allotransplant length equals the difference between linear size of dissected pathologic focus and length of segment, which constitutes 30% of length of entire tubular bone, increased by 1 cm. One end of allotransplant is introduced into bone marrow canal of distal fragment, the other end is introduced into metaepiphysis of proximal fragment. Allotransplant is fixed in proximal metaepiphysis of bone by means of crossing wires, onto which mounted is semi-circular support of Ilizarov's apparatus. Osteotomy of distal metaphysis is performed. Value of shortening and value of created diastasis are compensated by formed distraction bone regenerator in lower third of bone. Diastasis between bone fragments is eliminbated by dosed compression by bilocal compression-distraction osteosynthesis by Ilizarov. ^ EFFECT: method ensures prevention of extremity shortening in treatment of subtotal bone tumours and cysts of long tubular bones, reduction of treatment terms. ^ 1 ex, 3 dwg

Description

The invention relates to medicine, namely to orthopedics, and is used in the treatment of subtotal bone tumors and cysts of long tubular bones with linear dimensions of the pathological focus more than 30% of the entire bone length or a violation of the integrity of the cortical layer (lytic form of osteoblastoclastoma (OBK) with destruction of the cortical wall bones, fibrotic dysplasia with frequent relapses, with destruction of the bone wall of the cavity).

The aim of the invention is to reduce the treatment time and prevention of shortening of the limb in the treatment of subtotal bone tumors and cysts of long tubular bones with linear sizes of the pathological focus more than 30% of the length of the entire bone.

There is a method of treating metaphysical localization of osteoblastoclasts in children [1], which includes subperiosteal resection of a tumor within healthy tissue, replacing a defect with an autograft from the fibula, and applying an Ilizarov apparatus. However, this method is traumatic, since its use uses an autograft from the fibula. In addition, a free autograft is subsequently resorbed.

Closest to the proposed invention, in its technical solution, is a "Method for the treatment of benign tumors of long bones in children" [2]. This method includes bone osteotomy in the area between healthy and altered bone tissue, intraosseous resection of the pathological focus, followed by the introduction of a healthy bone fragment into the bone cavity, the formation of distraction regenerate and compression-distraction osteosynthesis according to Ilizarov. However, with subtotal lesions, when the pathological lesion is more than a third of the linear size of the tubular bone, it is not possible to introduce a healthy bone fragment into the formed bone cavity due to serious vascular complications. These significant vascular complications are unavoidable with the so-called “gathering” of soft tissues that occurs after any intervention aimed at shortening the bone segment. In addition, in order to form a mature bone regenerate, it is necessary to have a bone cavity with preserved cortical walls. With subtotal lesions of the tubular bone (with linear dimensions of the pathological focus more than 30% of the length of the entire bone), cortical walls are often completely absent, which makes the formation of regenerate impossible. That is, the “Method for the treatment of benign long bone tumors in children” [2] is applicable in the treatment of bone tumors and long tubular cysts with linear sizes of the pathological focus not more than 30% of the entire bone length, but its use is unjustified in subtotal pathological processes.

The essence of the invention lies in the combination of distinctive features sufficient to achieve the desired technical result, consisting in improving treatment outcomes while shortening its duration, preventing limb shortening in the treatment of subtotal bone tumors and cysts of long tubular bones.

This essence lies in the fact that a method of treating subtotal cystic formations or tumor-like diseases of the tubular bones involves knitting needles at the border of the epiphyseal growth zone and the tumor, with fixation of bone fragments, osteotomy of the bone in the area between healthy and altered bone tissue, resection of the pathological focus, replacement of the defect transplant with fixation of bone and graft fragments by percutaneous osteosynthesis apparatus, an osteotomy of the opposite end of the metaphysis and the formation of a distraction regenerator ata. A cortical allograft is introduced into the diastasis created between the bone fragments after resection of the tumor. The length of the allograft is equal to the difference between the linear size of the excised pathological lesion and the length of the segment, which is 30% of the length of the entire tubular bone, increased by 1 cm.The allograft is fixed in the proximal bone metaepiphysis with crossed needles on which the proximal semicircular support of the Ilizarov apparatus is mounted. The magnitude of the shortening and the magnitude of the resulting diastasis are compensated by the formed distraction bone regenerate in the lower third of the bone and the implantation of the graft into the medullary canal, while the diastasis between the bone fragments is eliminated by dosed compression by Ilizarov bilocal compression-distraction osteosynthesis.

The introduction of a cortical allograft into the resulting diastasis between bone fragments at the site of the resected tumor solves the problem of stabilization of bone fragments of bone formed after tumor resection. In the future, during compression between the supports of the Ilizarov apparatus, this transplant will act as a guide, preventing the displacement of bone fragments when they approach each other. It is known that, over time, allochost undergoes a process of resorption and replacement with healthy bone tissue, and therefore does not require further removal.

It is known that resection of a pathological section of bone tissue and creation of compression between bone fragments formed after a tumor resection is not possible if the size of the section of the resected bone is not more than 30% of the length of the entire bone segment, since the process of “softening” of soft tissues causes significant, sometimes irreversible, vascular complications in the limb. Therefore, to exclude neurovascular complications, the size of the allograft is selected equal to the difference between the linear size of the excised pathological focus and the length of the segment, which is 30% of the length of the entire tubular bone, and increases by 1 cm.

Fixing the graft, in the proximal metaepiphysis of the bone, with crossed knitting needles prevents its migration to the epiphyseal department, in addition, the proximal semi-ring support of the Ilizarov apparatus is mounted on the same knitting needles, i.e., the knitting needles in this case have a double function.

Allograft fixation in the distal bone is carried out by its implantation into the medullary canal. Tight fixation is provided by a preliminary selection of the diameter of the allograft according to the size of the medullary canal of the bone, which is determined by x-ray in the preoperative period.

Performing bilocal osteosynthesis with the Ilizarov apparatus is necessary to ensure compression between bone fragments to eliminate diastasis created after tumor resection. The magnitude of the shortening and the magnitude of the resulting diastasis are compensated by a distraction bone regenerate formed in the lower third of the bone.

The method is illustrated by the illustrations. Figure 1 shows the humerus with a bone tumor in the upper third, occupying more than a third of the entire length of the bone segment of the shoulder. Figure 2 - the humerus with a resected bone tumor and its replacement allograft. Figure 3 shows the humerus with a displaced intermediate fragment and distraction bone regenerate, making up for shortening the bone.

The method is as follows (for example, the humerus). Crossing knitting needles 1 (Fig. 1) are carried out in the distal part of the humerus, on which a half ring 2 is mounted. Retreating from the border of the healthy end of the bone, or the lower pole of the lesion, by an amount equal to the length of the removed area, crossing knitting needles are passed through the healthy metaphysis of the limb segment 3, on which the ring 4 is mounted. The half ring 2 and the ring 4 are connected by threaded rods. A longitudinal section in the area of the metaepiphysis, in the projection of the pathological focus, produces a single block of bone-soft tissue tumor formation (taking into account the possibility of involvement of the neurovascular bundle). Preserving the epiphyseal growth zone 5, with the adjacent unaffected portion of the metaphysis 6, perform segmental resection of pathologically altered bone tissue in one block 7 with surrounding soft tissues. An allograft 8 is prepared (FIG. 2) from a cortical bone with a diameter of not more than 10 mm. The length of the allograft is defined as the difference in the linear size of the excised pathological lesion and the segment, which is 30% of the entire length of the affected segment, increased by the depth of immersion of the graft in the medullary canal, which is usually about 1 cm. One end of the allograft 8 is inserted into the medullary canal of the distal fragment, and the other end, passing through the sprout plate 5, into the metaepiphysis of the proximal fragment 6, and is fixed by crossing needles 9, on which a half ring is mounted 10. Ring supports 4 and 10 are connected by threaded rods. The wound is sutured tightly, in layers. Between the supports of the Ilizarov apparatus 4 and 2, a corticotomy 11 is performed, as a result of which an intermediate fragment 12 is formed. After 3-4 days, the intermediate fragment 12 begins to move along the allograft 8, while replenishing the shortening due to the distraction regenerate 13 (Fig. 3). The rate of distraction is 1 mm per day. After replacing the defect and replenishing the anatomical length of the bone segment, the Ilizarov apparatus is stabilized and, after 4-6 weeks, dismantled. After discharge from the hospital, patients are put on a dispensary account. In the first year after surgical treatment, examinations of patients should be carried out every three months, in the second year - once every 6 months. Subsequently, with a favorable outcome of surgical treatment, patients are examined once a year. All examinations should be carried out with mandatory radiographic control.

Clinical example.

The patient Yves-lion, born in 1995, and / b No. 34782, was admitted to the Department of Pediatric Orthopedics on January 20, 2007 with a diagnosis of lytic form of osteoblastoclastoma of the upper third of the humerus. On the presented radiographs, the pathological process of the upper third of the humerus is determined, occupying about half the length of the left humerus. This process is limited by the preserved proximal epiphyseal area of the growth of the humerus. The cortical layer of the bone along the inner part of the pathological focus is not traced. January 24, 2008 the operation was performed: segmental resection of the tumor, bilocal osteosynthesis with the Ilizarov apparatus, bone grafting with a cortical allograft. Immediately before surgical treatment, linear parameters were measured by an X-ray: the length of the segment of the humerus 41 cm, the length of the pathological focus 19 cm. We determined the possible size of the soft tissue, which is 30% of the length of the segment of the humerus, which means 12.3 cm. immersion of the graft into the medullary canal by 1 cm, the necessary graft length was obtained: 19 cm -12.3 cm + 1 cm = 7.7 cm. The thickness of the medullary canal was determined from the radiograph and the allograft was selected for annogo patient.

The operation was performed under general anesthesia. After processing the surgical field, a half-ring support was superimposed on intersecting needles in the distal humerus, on which a distal half-ring was mounted. Retreating from the border of the healthy end of the bone, or the lower pole of the lesion, by an amount equal to the length of the removed area, crossed needles were crossed through a healthy metaphysis of a limb segment, on which an intermediate ring was mounted. Semicircular and annular supports were connected by threaded rods, after which a longitudinal section in the area of the metaepiphysis in the projection of the pathological focus made the selection of a bone-soft tissue tumor formation in one block. Preserving the epiphyseal growth zone, with the adjacent unaffected metaphysis, we performed a segmental resection of pathologically changed bone tissue, in one block with the surrounding soft tissues. An allograft prepared before surgery was implanted into the medullary canal of the distal fragment, and the other end was inserted into the metaepiphysis of the proximal fragment and fixed with crossing needles on which the proximal half-ring was mounted. The intermediate annular support and the proximal half ring were connected by threaded rods. The wound was sutured tightly, in layers. A corticotomy was performed between the intermediate annular support and the distal semicircular support with a chisel. The operation was completed by installing drainages and applying aseptic dressings to the wounds and around the needles. On the 4th day after the operation, the intermediate fragment of the humerus along the allograft began to move towards compression, while replenishing the shortening by creating a distraction regenerate in the lower third of the humerus. The rate of distraction is 1 mm per day. The period of replacement of the defect and replenishment of the anatomical length of the bone segment was 201 days (the patient spent 36 days in the hospital, the rest of the time on an outpatient basis). After that, the Ilizarov apparatus was transferred to stabilization mode and after 16 weeks it was dismantled. After this, the patient received physiomechanotherapy and rehabilitation treatment. Examined a year after the end of treatment. Complete recovery of the segment with satisfactory functional outcomes is noted.

Information sources

1. Fedotov V.K. et al. Osteoblastoclast treatment technique for metaphysical localization in children. Orthopedics, traumatology and prosthetics, 1981, 9, 49.

2. A.S. USSR No. 1406844, A61B 17/56, BIPM, 2002, No. 24.

Claims (1)

A method for the treatment of subtotal cystic formations or tumor-like diseases of the tubular bones, including knitting needles at the border of the epiphyseal growth zone and the tumor, with fixation of bone fragments, bone osteotomy in the area between healthy and altered bone tissue, resection of the pathological focus, replacement of the defect with a graft, with fixation of bone fragments and transplant by transosseous osteosynthesis apparatus, an osteotomy of the opposite end of the metaphysis and the formation of a distraction regenerate, characterized in that in a stasis created between bone fragments after a tumor resection, a cortical allograft is introduced, the length of which is equal to the difference between the linear size of the excised pathological focus and the length of the segment, which is 30% of the length of the entire tubular bone, increased by 1 cm, fix it in the proximal bone meta-epiphysis with crossed knitting needles, on which the proximal semicircular support of the Ilizarov apparatus is mounted, the magnitude of the shortening and the magnitude of the resulting diastasis are compensated by the formed distraction bone regenerate in the lower third of the bone and implant the graft into the medullary canal, while diastasis between the bone fragments is eliminated by dosed compression by Ilizarov bilocal compression-distraction osteosynthesis.

Images