RU2473317C1 - Method of treating fractures of proximal part of femur in conditions of osteoporosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to orthopedics and traumatology, in particular, to methods, used in surgical treatment of hip fractures. Reposition of fracture is performed by skeletal traction by femur condyles, and preliminarily, before introduction of intramedullar rod, fracture is fixed by means of wires, passed from subtrochanteric region into femur neck and head under X-ray or EOC control. Test for stability of temporary wire fixation is carried out by removal of skeletal traction load, which is placed back after test. Skeletal traction is continued during operation. Intramedullar rod is introduced into femur. Neck fixing screw is introduced into femur neck through hole in proximal part of intramedullar rod. Static blocking of rod is performed. X-ray control is carried out. Skeletal traction is removed. Fixing wires are extracted. Skin is sutured. 2-3 months after operation additional compression of bone fragments at the level of fracture is realised by removal of upper blocking screw from diaphyseal part.

EFFECT: method ensures fusion of fragments of proximal part of femur in anatomically correct position, prevention of metal fixer migration, reduction of inpatient treatment terms.

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Description

The invention relates to medicine, in particular to orthopedics and traumatology, in particular to methods used in the treatment of fractures of the proximal femur with a surgical method.

A known method of treating fractures of the proximal femur by percutaneous osteosynthesis with at least 4 fixators with multi-step thread (Gear N.A. Femoral neck fractures: Modern methods of treatment / N.A.Shesternya, Yu.S. Gamdi, S. V. Ivannikov. - M.: BINOM. Laboratory of knowledge, 2005. - 104 pp., Ill.). An important element of the fixator is a persistent thread on the front of the fixator for contact with the spongy bone of the femoral head and a thread on the cone in the distal part of the fixator, which is in contact with the cortical bone in the undervert region. The length of the retainers varies in accordance with the anatomical features of the femoral neck. To install the latch for this method using a special set of tools and an orientation system in volume. After a closed reposition of the fracture, on the orthopedic table through the conductor and centering sleeves, the channels are drilled under the clamps in the optimal directions - diverging relative to the frontal plane and converging relative to the central axial line of the femoral neck in the frontal plane, that is, on a direct x-ray. After surgery, the patient is allowed a gentle load on the operated limb for 2.5-3 months, before the onset of fracture consolidation.

However, this method does not provide stable osteosynthesis of bone fragments in cases of over - and under-fracture femoral fractures, since fixators in the form of screws are fixed on the cortical bone only in the region of the greater trochanteric slope, and when the load on the operated limb, secondary displacement of fragments with neck variation and migration fixatives for osteoporosis of the head and neck of the femur.

A known method of treating comminuted fractures of the femur, in which the localization of the fracture, sizes and shapes of fragments of the injured bone is assessed, a pin with a hole at its proximal end is inserted through the proximal fragment into the bone marrow canal, a hole is formed in the proximal fragment on one axis with hole in the pin, fix the position of the pin by inserting the rod through the holes in it and in the proximal fragment, draw through the distal fragment of the bone two crosswise knitting needles at a distance of about 5 cm along the injured bone from each other, fasten the needles in the annular external supports of the transosseous device, insert screws into the fragments from the opposite sides of the injured bone with the possibility of providing lateral compression, after which the screws and the shaft are fixed in the transosseous device - in its beam and annular external supports, which allows simultaneous longitudinal and lateral compression to exclude secondary displacement of fragments (Pat. RU No. 2402301. Publ. 10/27/2010).

However, the known method does not prevent the migration of the inserted pin in the proximal section with the cutting of the neck screw through the head and neck of the femur under conditions of osteoporosis after the onset of an active load on the injured limb, since compression at the junction of the fragments is performed by the transosseous device only at the stage of fusion. After removal of the apparatus, additional compression at the junction of the bone fragments cannot be carried out, thus it is impossible to prevent the development of secondary displacement of the fragments and the migration of the metal fixator.

A known method of treating fractures of the proximal femur using osteosynthesis with a proximal femoral nail (PFN - proximal femoral nail) (Aesculap (Germany), ChM (Poland), Synthes (Switzerland)). After a closed reposition of the fracture, on the orthopedic table under the control of the image intensifier tube, a guide needle with a centralizer for a cylindrical cutter is inserted into the top of a large trochanter. Then, a bone marrow cavity is opened using a cylindrical cutter; round rasp, repeating the shape of a nail, expand the channel. A nail mounted with a guide, of a selected length and diameter, is introduced into the channel. On the guide, channels are made in the neck of the femur and the derotational and fixation screws are inserted. Weaken the traction on the orthopedic table and perform distal nail blocking with two screws drawn through both cortical plates of the diaphysis along the guide into the special round nail holes located in its distal part. Dosed load on the operated limb is prescribed for 3-5 days after the operation (V. M. Shapovalov, V. V. Khominets, S. V. Mikhailov. Fundamentals of internal osteosynthesis. - M .: GEOTAR - Media, 2009. - 240 p. : ill.).

However, the treatment of proximal femoral fractures with this method of osteosynthesis with an intramedullary rod with distal blocking through round holes, without the possibility of additional compression of bone fragments in the distant period after the injury, does not exclude the development of secondary displacement of the femoral fragments in the fracture area and rod migration in the proximal direction with eruption neck screws through the head and neck of the femur in conditions of osteoporosis.

The objective of the present invention is the ability to create additional compression at the junction of fragments in the fracture region, due to which the metal fixation is prevented during the load on the limb with porous bone tissue, early activation of elderly patients becomes possible and the conditions for fracture fusion are improved.

The task is carried out as follows in a method for the treatment of fractures of the proximal femur in conditions of osteoporosis, including reposition of the fracture under the control of the tube, using spokes, a conductor, fixing fragments of the femur bones with an intramedullary shaft, followed by early loading of the limb, and repositioning the fracture by skeletal traction beyond the femoral condyle and previously , before the introduction of the intramedullary shaft, the fracture is fixed with knitting needles, which are carried out from the subrovert region to the neck and femoral head with X-ray or EOP control, a test is performed on the stability of temporary fixation with needles by removing the load of skeletal traction, which is returned after the test, skeletal traction is continued during surgery, an intramedullary shaft is inserted into the femur, a cervical neck is inserted through the hole in the proximal part of the intramedullary shaft fixing screw, perform static blocking of the rod, carry out x-ray control, remove skeletal traction, remove the fixing spokes, y is sutured, after 2-3 months after surgery performed additional compression of the bone fragments at the fracture level by removing from the diaphyseal portion of the upper locking screw.

The present invention is illustrated by a detailed description, a specific example of the method with links to copies of x-rays, in which:

Figure 1 (a, b) is a copy of the x-ray of the femur in a straight line (a) and axial (b) projections after osteosynthesis of a comminuted fracture of the proximal femoral metadiaphysis with an intramedullary shaft with a cervical locking screw and locking cortical screws.

Figure 2 (a, b) - represents a copy of the x-ray of the femur in a straight line (a) and axial (b) with a fracture of the proximal femoral metadiaphysis 2.5 months after surgery before removing the blocking cortical screw from the round hole in the diaphyseal part; There are initial signs of fracture consolidation and areas of bone resorption in the neck screw region.

Figure 3 (a, b) - represents a copy of the x-ray of the femur in direct and axial projections 9 months after surgery with a consolidated comminuted fracture of the proximal femoral metadiaphysis; there are no signs of rod migration, the cortical diaphyseal screw from the round hole is removed.

A method of treating closed fractures of the proximal femur in osteoporosis is as follows.

Upon admission to the clinic a patient of an older age group with a fracture of the proximal femur and radiological signs of osteoporosis carry out skeletal traction with a knitting needle for the femoral condyle. With the consent to surgical treatment, the patient is placed on the operating table in a supine position while maintaining skeletal traction. After anesthesia, a closed manual repositioning of the lesion is performed. Then, under the control of the image intensifier, 2-3 knitting needles are made from the subtrochial. To do this, they are carried out longitudinally along the axis of the femoral neck, so that they do not interfere with the subsequent introduction of the femoral intramedullary shaft and the cervical fixing screw. With this, knitting needles are the connecting elements of the diaphysis and the proximal part of the thigh.

The spokes performed in this way create temporary stability and prevent the displacement of fragments of the femur at the time of insertion of the intramedullary shaft. Next, form the point of introduction of the rod through the apex of the greater trochanter. A conductor is introduced through the formed hole. Then, an intramedullary rod is inserted into the femur along the conductor, after which the conductor is removed. According to the conductor, through the hole in the proximal part of the intramedullary shaft, a guide needle is drawn into the neck of the femur to orient the cervical fixing screw. A drill is inserted along the guide needle, with the help of which a channel for the neck screw is prepared, while the drill should not go beyond the contours of the femoral head. Insert the neck screw.

Further, according to the conductor and under the control of the image intensifier, 2 blocking cortical screws are inserted into the diaphysis of the femur through 2 holes in the diaphyseal part of the intramedullary shaft, the distal opening has an oval shape. In conditions of osteoporosis, prior preparation of the cortical bone is not required with a tap. The rod is statically blocked by tightening the screws in both cortical diaphysis plates. The distal screw is inserted into the proximal part of the oval hole.

Then carry out x-ray control of the position of the fragments of the thigh, the position of the rod and screws. With a satisfactory position of the fragments of the thigh, intramedullary shaft and fixing screws, skeletal traction is removed, the spokes are removed. The skin is sutured.

In the postoperative period, on the second day after the operation, the patient is allowed a metered load on the leg. After 2-3 months, additional compression is performed at the junction of the bone fragments at the fracture site. For this, the upper blocking cortical screw is removed from the diaphyseal part of the retainer, and the distal screw in the oval hole is left. Due to the oval shape of the hole under load on the limb, additional compression of the fragments in the fracture area is carried out. In this case, the metal fixer does not migrate in the proximal direction.

A clinical example of the method.

Patient P., 75 years old, was taken by the ambulance team to the emergency room of the Central Clinical Hospital No. 24; Yekaterinburg with a closed comminuted fracture of the proximal femur. During hospitalization, the skeletal traction of the femoral condyles was imposed on the trauma unit No. 1, which made it possible to eliminate shortening along the length. On the 4th day after admission and preoperative examination, the patient was taken to the operating room. After anesthesia, the patient was laid on the operating table in a supine position while maintaining the skeletal traction system. Under the control of the image intensifier, the fracture was repositioned on skeletal traction, the displacement of the fragments in width and their rotational displacement were eliminated, and diafixing spokes were drawn from the undervert region through the neck to the femoral head. We conducted a test on the stability of fixation with knitting needles by temporarily removing the load used for skeletal traction. After a skin incision and formation with a drill in the area of the apex of the greater trochanter, the entry point into the femoral canal was inserted into the femoral canal. Then, a rod was drawn through the conductor into the femur. Using a conductor, through a hole in the proximal part of the rod, a guide needle was drawn into the neck of the femur to orient the cervical fixation screw. A drill was introduced along the guide needle, with the help of which a channel for the neck screw was prepared. Next, a cervical screw was introduced. Using a conductor, blocking cortical screws were inserted into the femoral diaphysis through the openings of the intramedullary shaft in its diaphyseal part and under the control of the image intensifier tube. A distal locking screw was inserted into the proximal portion of the oval opening. Radiography of the hip joint was performed in a direct and axial projection, on which a satisfactory position of the bone fragments was determined (Figure 1). After that, skeletal traction was removed. The skin was sutured and aseptic dressings applied.

On the second day after the operation, the patient was activated, the metered load on the leg was allowed, on the 14th day after the operation, the patient was discharged from the hospital. 2.5 months after surgery on a consultative appointment, the patient noted pain in the proximal femur during exercise, along with signs of fracture consolidation, signs of bone resorption and lysis of the bone around the cervical screw were revealed (Figure 2). To prevent the migration of the metal fixator under conditions of osteoporosis, a blocking cortical screw was removed from the round opening, due to which additional compression of the fragments at the fracture site was carried out.

9 months after the operation at the follow-up examination, the fusion at the fracture site and the absence of rod migration with fixing screws in the porous bone tissue of the thigh were X-ray determined (Figure 3). The end result is regarded as good, limb function is restored, the patient is happy with the treatment, no complications were observed.

The proposed method for the treatment of fractures of the proximal femur in conditions of osteoporosis is safe and economical, it allows to achieve satisfactory reposition and fixation of bone fragments, their reliable fusion due to additional compression of bone fragments, performed 2-3 months after surgery, at the beginning of an active load on the operated limb . The rehabilitation period of patients treated with this method takes place at home, which contributes to the full social adaptation of patients, especially the elderly. In addition, the proposed method allows to achieve anatomically correct relationship of the position of the fragments of the femur and restore health in a short time.

The method is used in the Central city clinical hospital No. 24 of the city of Yekaterinburg.

Claims (1)

A method for treating proximal femur fractures in conditions of osteoporosis, including reposition of the fracture under the control of an EOP, use of knitting needles, a conductor, fixing fragments of the femur bones with an intramedullary nail followed by early loading of the limb, characterized in that the fracture is repositioned by skeletal extension of the femoral condyle and previously, until the introduction of the intramedullary shaft is fixed by a fracture with knitting needles, which are carried out from the subrovert region to the neck and femoral head under an X-ray or ICT con role, perform a test on the stability of temporary fixation with needles by removing the load of skeletal traction, which is returned after the test, skeletal traction is continued during surgery, an intramedullary shaft is inserted into the femur, a cervical fixing screw is inserted through the hole in the proximal part of the intramedullary shaft, static blocking of the rod, X-ray control is carried out, skeletal traction is removed, fixing knitting needles are removed, the skin is sutured, 2-3 months after era tio perform additional compression of the bone fragments at the fracture level by removing from the diaphyseal portion of the upper locking screw.

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