RU2551618C2 - Method for minimally invasive osteosynthesis of long bones and device for implementing it - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions refers to traumatology and orthopaedics, and can be applicable for minimally invasive osteosynthesis of long bones. The skin is incised 5-7 cm above a bone fracture. After a supraosseous tunnel is created, a plate is inserted with its pointed tip advanced, positioned above the fracture and mounted thereabove. A hollow rod is screwed into a wide portion of an extreme hole of the plate until fastened tightly. A guide pin is inserted through the rod and screwed in a bone drill plate. After the bone hole is created, the guide pin is removed, and a retention screw is inserted with a head screwed into the hole with the plate fastened incompletely. The plate is corrected along the bone, and once the extreme hole of the plate detected, the prick is made at its level. The hollow rod is inserted and screwed into the wide portion of the extreme hole of the plate. A drill guide pin is delivered through the rod cavity, screwed into the hole of the plate, and the bone is drilled; after passing the both cortical layers, the screw is inserted. If the plate position is found to be correct, the upper and lower screws are tightened; a flat pattern is stringed onto the superior hollow rods; the hole positions are marked and pricked at the level; a required quantity of the screws is inserted alternatively.

EFFECT: group of inventions enables reducing the osteosynthesis time, reducing the soft tissue injuries and the risk of postoperative infectious complications.

2 cl, 5 dwg

Description

The invention relates to medicine, namely to traumatology, and is intended for the treatment of fractures of long bones, such as the tibia.

A known method of minimally invasive osseous osteosynthesis of long bones: Litvinov II, Klyuchevsky VV Minimally invasive osteosynthesis with closed fractures of the lower third of the tibia // Bulletin of Traumatology and Orthopedics. N.N. Priorov. 2006. No1. S.13-17. "The implementation of this method is carried out under constant visual control on the monitor of an electron-optical transducer of an x-ray image (image intensifier tube). Above and below the fracture zone, access is made to the outer surface of the proximal fragment of the damaged bone. Between the two accesses, a tunnel is stupidly formed along the anteroposterior surface of the bone, through which a pre-modeled lockable plate is introduced from the bottom up. Produce preventive indirect manual reposition. Then the plate is positioned on the bone and fixed to the distal fragment of the damaged bone through a non-threaded hole with a pulling spongy screw. Through the sleeve screwed into the distal threaded hole, enter the Kirschner needle to mark the position of the distal locking screw relative to the fracture line. An opening is formed in the proximal fragment outside the plate, by which the displacement along the length is eliminated by the use of a distraction device. The position of the achieved correction is fixed with another Kirschner spoke inserted through the sleeve in the threaded hole of the proximal end of the plate. Perform control x-ray. Eliminate deformation in the frontal plane by removing the Kirschner needle from the distal fragment and loosening the spongy screw by turning around the last lower fragment of the damaged bone. Then the spongy screw is tightened again. The final fixation is performed by inserting a plate of locking screws into the distal fragment through the threaded holes, into the proximal fragment - a monocortical attracting screw until the edge of the plate contacts the bone and monocortical screws with angular stability. ”

When performing the proposed operation, the difficulty of retaining fragments in a manual repaired state is manifested.

The operation of fixation and reposition of bone fragments from the distal section begins, which contradicts the principle of reposition of bone fragments.

Prolonged monitoring during the installation of screws with an image intensifier tube is dangerous for the health of the patient and employees present in the operating room.

Significant duration of surgery.

The known "method of minimally invasive osseous osteosynthesis of diaphyseal fractures of long tubular bones", patent RU No. 2348371, 2009.

Closed manual reposition is performed to eliminate coarse bias and interposition of soft tissues. A skin incision is made about 4 cm long above the distal fragment. A blunt long raspator produces the formation of a bed for the plate by sliding along the surface of the bone. The matched plate is modeled by clamping the distal end with a screw clamp. Mark the projection of the plate holes on the guide frame of the device on a graduated scale using a movable slide-guide. The fixed plate is inserted into the bed formed by the raspator. They are fixed with screw rods, one of which is inserted into the distal fragment to the second cortical layer, then fixed to the guide frame. The second screw-rod is inserted into the proximal fragment with a deviation of 15-20 degrees in the sagittal plane 2-3 cm proximal to the fracture site, after which it is also fixed to the guide frame. Using nodes located on the screw nozzle, the displacement along the width of the rotational and angular displacements, as well as the displacement along the length by compression along the screw nozzle, are eliminated. After achieving reposition, all nodes of the guide frame are rigidly fixed. According to the projections of the plate openings previously marked on the graded scale of the guide frame, a movable guide slider is installed, through which a protector guide and a trocar are introduced. Dots are marked on the skin, a soft tissue incision is made. The protector guide with the trocar is immersed in the incision to the cortical layer of the bone. The trocar is removed, a guide for the drill is introduced, through which a hole is drilled through two cortical layers. A screw length gauge is inserted into the hole drilled in the bone, then a specific screw is screwed into the drilled hole through a tread guide using a screwdriver. The remaining screws are inserted in a similar manner. The distal end of the plate is released, loosening the fixing screw, the rod screws are removed.

In this invention, the guide-slider does not provide accuracy in determining the location of the plate and its holes.

It is difficult to align the screws to secure the plate.

Quite a high invasiveness of the operation.

A significant duration of the operation of osteosynthesis.

A series of osseous plates used for minimally invasive osseous osteosynthesis is currently used.

As analogues of the proposed device used patents for the invention: RU No. 2022534, RU No. 2025096, RU 2348371, RU No. 2093094, RU 2483690

Closer to our method device can be considered patent RU No. 2093094 "Method for bone osteosynthesis of a tibial fracture in the absence of rotational displacements and a device for bone osteosynthesis", including matching fragments, applying a plate to the fracture zone and fixing it with screws, characterized in that through Screws are inserted into the fragments of the skin into the fragments, located under the skin, and the fragments are fixed with a plate with a longitudinal groove open from the point of sharpening drawn into the fracture zone through the transverse incision of soft tissues with a width corresponding to the width of the plate, proximal to the extreme of the screws.

 A device for bone osteosynthesis containing a plate with screw holes, one end of which is obtuse and the other has a point, characterized in that the device is equipped with a holder with a guide rod and an element for fastening the obtuse end of the plate, the hole for the screws in the plate is made in the form of a longitudinal groove open from the side of the pointed plate.,

Both in the method and the device there are manifestations that do not allow the implementation of full osteosynthesis.

Firstly, the process of holding the plate creates a fear of capture and damage to soft tissues. Secondly, the impression of doubtfulness of the fixing properties of the proposed plate. Thirdly, the guide rod does not create a guideline for the plate.

The aim of the invention is to improve the quality of the operation of osteosynthesis while reducing the time for surgery, and reducing trauma to soft tissues, and reducing postoperative infectious complications.

A preliminary version of the formula of the proposed method and device

Method for minimally invasive osseous osteosynthesis of long bones and device for its implementation

Through the proximal and distal sections of the long bone, knitting needles are carried out with the Ilizarov apparatus half-rings fixed to them, connected with three screw rods and given distraction until the position of the bone fragments is corrected and repositioned, access is made to the damaged bone using a 3-4 cm incision above the proximal fragment , stepping up 5-7 cm from the fracture line, depending on the extent of the bone destruction zone. A bed-tunnel is formed for the insertion of the osseous plate and is carried out with a pointed end, bypassing the site of a bone fracture with the orientation of the image intensifier. The hollow rod is screwed into the extreme wide hole of the plate, until the screw is fully fixed and the guide is inserted through it and screwed into the plate to hold the bone drill, and after the bone hole is created, the guide is removed and the fixing screw is inserted with a cap with a cylindrical thread into the screw hole without fully fixing the plate . The plate is corrected along the bone under the control of the image intensifier tube and, when the extreme hole of the plate is detected, a puncture is made at its level and a hollow rod is inserted and screwed into the extreme wide hole of the plate. A guide for the drill is passed through the cavity of the rod, screwed into the small hole of the plate and drilled a bone, after passing through both cortical layers, a screw is inserted and, when the plate is correctly located under the control of the tube, the upper and lower screws are tightened to the limit. When assessing the correct position of the plate relative to the bone and its fixing properties on the protruding hollow rods, a plate template is strung that completely repeats the shape and location of the holes through which marks are made to match the holes of the template with a bone plate immersed under the tissue; holes are made in the skin, guides are drawn, and plates are screwed into the holes through which the bone holes are drilled and, when the guides are removed, the required number of screws are inserted, depending on the nature and type of bone fracture.

The inventive device for bone osteosynthesis is characterized in that it is made in the form of a rounded-pointed plate at one end with a transverse bend with a number of threaded cylindrical holes cut on the bend top at an angle of 20 degrees in opposite directions, with a gap free of holes in the middle of the plate in пластины the length of the plate, and the extreme holes with different diameters in the thickness of the plate, on which respectively a cylindrical thread is applied, one upper - from the upper surface of the plate, with a wide hole, half the thickness of the plate, for the introduction of a hollow rod, the other is the lower one, from the bottom surface of the plate, closer to the bone, for the introduction of a conductor for drilling the bone and then screwing the screw head when blocking, in the vertical direction. The extreme holes are located vertically, that is, perpendicular to the plane of the plate, at an angle of 90 degrees. The device complex includes a template that completely repeats the shape and structure of the plate, only the extreme openings are wider than the openings of the plate for penetration of the hollow rod and passage of the conductor, and a drill to create holes in the bone and insert an intraosseous screw.

Technical result

The technical result of the invention consists in solving the previously posed problem of closed reposition of a multi-fragmented fracture by a distraction method, increasing the accuracy of introducing fixation elements of the osseous metal structures while maintaining adequate blood supply to both the fracture area and the entire segment throughout the installed plate. The implementation of small punctures-cuts of the skin up to 1 cm long without additional trauma to the soft tissues allows the installation of a bone plate without the risk of damage to the soft tissues. The set of signs of the implementation of the claimed in this application method reduces blood loss, the risk of infectious complications, reduces the time of surgery. The proposed plates can be produced by domestic industry and may be available to a wide range of orthopedic traumatologists.

The inventive device is illustrated using the drawings, which depict all the details of the device for bone osteosynthesis. In the drawings, positions 1-5 indicate "Device for minimally invasive osteosynthesis of long bones"

Figure 1. Top view of the plate.

Figure 2. Side view of the plate.

Figure 3. The plate is cut in the end.

Figure 4. The device is assembled: a tube is screwed to access the plate with the introduction of a conductor for drilling a bone hole and with a screw screwed into the bone and screw caps into the plate.

Figure 5. Plate template.

The method of minimally invasive osteosynthesis of long bones and a device for its implementation are used as follows. Lay the patient on the operating table. Through the proximal and distal sections of the long bone, Kirschner spokes are held with the Ilizarov apparatus half-rings fixed to them, connected with three screw rods and given distraction until the position of the bone fragments is corrected and repositioned, access to the damaged bone is made using a 3-4 cm section above the proximal fragment, stepping up 5-7 cm from the fracture line, depending on the extent of the bone destruction zone. A bed-tunnel is formed for the insertion of the osseous plate (Fig. 1) and is carried out with a pointed end, bypassing the site of bone fracture with the orientation of the tube. The hollow rod is screwed into the outer hole of the plate until it is fully fixed and a guide is inserted through it and screwed into the plate to hold a bone drill, and after the bone hole is created, the guide is removed and a fixing screw is inserted with a cap with a cylindrical thread into the screw hole without fully fixing the plate (diagram reflected in figure 4). The plate is corrected along the bone under the control of the image intensifier tube and, when the extreme hole of the plate is detected, a puncture is made at its level and a hollow rod is inserted and screwed into the extreme wide hole of the plate. A guide for the drill is passed through the cavity of the rod, screwed into the small hole of the plate and drilled a bone, a screw is inserted after passing through both cortical layers (the flow diagram is shown in Fig. 4), and when the plate is correctly located under the control of the tube, the upper and lower screws are tightened to the limit . When assessing the correct position of the plate relative to the bone and its fixing properties on the protruding hollow rods string string plate (figure 5), completely repeating the shape and location of the holes through which marks are made matching holes of the template with a bone plate immersed under the tissue; holes are made in the skin, guides are drawn and screws are inserted into the holes through which the bone holes are drilled and, when the guides are removed, the required number of screws are inserted, depending on the nature and type of bone fracture, and hollow rods are removed, wounds are sutured. Remove the distraction apparatus.

Perform control radiography in two projections.

Example. Patient B., 38 years old. Received after a road injury two hours later. Examined. Diagnosis. Closed comminuted fracture with / 3 bones of the right tibia with displacement of fragments. In the absence of contraindications taken to the operating room. Through the proximal and distal sections of the tibia, Kirschner spokes are drawn, half rings from the Ilizarov apparatus are fixed to them. Between them set the rods with screw thread. Give distraction. Spend correction of fragments. In the proximal part of the lower leg, departing from the edge of the fracture of 5 cm, make an incision along the front surface of the lower leg of 4 cm to the tibia. Using the elevator, from top to bottom with caution, bypassing the fracture area with the transition to the distal fragment, make a tunnel through which the plate is passed with its pointed end down. A hollow rod is screwed into the upper hole of the plate, through which a drill guide is inserted and a hole is drilled into the bones through both cortical layers. The guide is removed and a bone screw is inserted through the hole made, which is screwed to half the thread of the head. Using the image intensifier tube, the extreme hole of the distal plate section is revealed and a puncture incision is made in the trocar through which a hollow rod is inserted and screwed into the plate, through which a guide is inserted and screwed into the small hole of the plate, and a bone is drilled through both cortical layers. The conductor with the drill is removed and a screw is inserted; after additional correction of fragments, both screws are screwed tightly. Then, a template is put on the protruding hollow rods and holes are marked on the skin matching the holes of the immersed plate. In the field, punctures are made, through which screws are inserted and screwed into the bone and into the plate. Stitches to the skin. X-ray control. Remove the distraction apparatus.

Claims (2)

1. The method of minimally invasive osteosynthesis of long bones, namely, that they perform a closed reposition of fragments of the damaged bone using a distraction apparatus, access the damaged bone using an incision 3-4 cm long, form a bed for subsequent insertion of the osseous plate, characterized in that a skin incision is carried out above the bone fracture by 5-7 cm, after creating the periosteal tunnel, insert the plate according to claim 2, advance it with the pointed end forward, orient it over the fracture and set it over it, in a wide part of the plate’s outer hole is screwed into the hollow shaft until it is fully fixed, a guide is inserted through the shaft and screwed into the plate to hold the bone drill, after the bone hole is created, the guide is removed and the fixing screw is inserted with the cap screwed into the hole without completely fixing the plate, the plate is corrected along the bone and revealing the extreme hole of the plate, make a puncture at its level, introduce a hollow rod and screw it into a wide part of the extreme hole of the plate, passing through the cavity of the rod drill guide, screw into the hole of the plate and drill a bone, after passing through both cortical layers, a screw is inserted, when the plate is found correctly, tighten the upper and lower screws, string up the hollow rods string the template according to claim 2, mark the position of the holes at the level of which punctures, and the required number of screws is inserted in turn. 2. A kit for minimally invasive osteosynthesis, including a device for minimally invasive osteosynthesis, containing a plate with screw holes, one end of which is obtuse and the other has a point, the plate is equipped with a holder with a guide rod and an element for attaching the obtuse end of the plate, the hole for screws in the plate is made in the form of a longitudinal groove open on the side of the pointed plate, the plate has a transverse bend and a sharply-rounded distal end with a series of threaded cylindrical holes cut into bending fault, the extreme ones are vertical, and the following are at an angle of 20 degrees with alternation in opposite directions, in the middle of the plate there is a gap of ¼ the length of the plate free from holes, the extreme holes of the plate of unequal diameter across the plate thickness, they have a two-story cylindrical thread, one upper-wide, for the introduction of a hollow shaft, the other-lower-small for the introduction of the conductor, and drilling the bone, and the subsequent screwing of the screw head when blocking, the kit also includes a template that completely oryayuschy shape and structure of the plate, with extremes larger openings for the penetration of the hollow rods.

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