RU2578839C1 - Method for elimination of metacarpal bone defect with loss of distal portion and replacement of fetlock joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to traumatology and orthopaedics in endoprosthesis replacement metacarpophalangeal joints in conditions of evident metacarpal bone defect with shortening length. At first stage of surgical treatment of metacarpal bone osteotomy is performed at boundary of its diaphysis and proximal epiphysis. Method includes application of mono-plane external fixation apparatus and a distal fragment of metacarpal bone in required position. Value of distraction is calculated by x-ray images. At second stage of treatment, method includes filling formed diastasis between fragments of metacarpal bone autograft of iliac crest and endoprosthesis fetlock joint with leg proximal joint component in stored marrowy canal displaced metacarpal bone fragment.

EFFECT: method prevents development of instability of proximal component due to preservation of density of cortical wall displaced metacarpal bone fragment.

1 cl, 1 ex, 4 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used for endoprosthetics of the metacarpophalangeal joints in conditions of a pronounced defect of the metacarpal bone with a shortened length.

Endoprosthetics to restore the mobility of the metacarpophalangeal joints of the fingers is widely used in rheumatoid polyarthritis. However, with post-traumatic deformities, the use of endoprosthetics according to the classical technique is limited. One of the most common reasons for refusal of the endoprosthetics of the metacarpophalangeal joints is a defect of the metacarpal bone with the loss of its distal part, resulting from injuries or diseases and which is a contraindication for performing such interventions. (Vodyanov H.M., Ovchinnikova Z.S., Robina S.I., 1985; Aselin F., Pradet G., Gouet O., 1985). The standard technique for performing endoprosthetics is performed by resecting the articular ends of the articulating phalanges, modeling the bone marrow channels in accordance with the shape and size of the legs of the endoprosthesis, and implanting the implant in place of the resected joint. The disadvantage of this method is that with significant defects in the metacarpal bones, endoprosthetics cannot be performed due to insufficient leg length. In such cases, one has to resort to the use of individually made prostheses, which sharply increases the cost of treating the patient and does not always ensure the stability of the proximal component. The task to which the invention is directed is to restore the length of the metacarpal bone while preserving its bone marrow canal, which allows performing endoprosthetics of the metacarpophalangeal joint.

Known two-stage method for the restoration of osteoarticular defects of the hand. The first step is to replace the defect of the articular ends with an autograft of the cortical-spongy structure taken from the iliac crest in accordance with the size of the bone defect. If the joint ends are defective, the non-viable ends of the bone fragments are resected, free-lying bone fragments are removed. A cortical-spongy graft is introduced into the resulting defect. Stability is achieved by means of end-to-end osteosynthesis with knitting needles or by treating the ends of the graft with special cylindrical cutters with their subsequent introduction into each other. The second stage - joint arthroplasty - is performed after the reconstruction of the graft and the formation of the channel in the spongy part of the bone graft for the leg of the prosthesis. This method makes it possible, in the presence of a large defect in the articular ends of the phalanges and metacarpals, to maintain the normal length of the finger and provide a certain restoration of joint function (Endoprosthetics of the joints of the fingers in patients with post-traumatic deformities of the hand. SV Petrov, NL Korotkova. Methodical recommendations . - Nizhny Novgorod. - 1992. - 10 p.). However, this method does not allow to restore or maintain the bone marrow canal, which limits the possibilities of arthroplasty and increases the risk of postoperative complications in the form of instability of the proximal component of the joint.

The technical result of the invention consists in the possibility of performing endoprosthetics of the metacarpophalangeal joints of the hand with standard prostheses in the presence of significant defects of the metacarpal bones; in preserving the bone marrow canal of the bone site, thereby expanding the possibilities of endoprosthetics and reducing the risk of instability of the proximal component of the joint due to displacement of the osteotomized fragment of the metacarpal bone in the distal direction at the first stage of surgical treatment; in reducing the treatment time due to the simultaneous replacement at the second stage of treatment of the created diastasis between the fragments of the metacarpal bone and endoprosthetics of the metacarpophalangeal joint; minimize the risk of purulent complications by reducing the number of surgical interventions.

The result is achieved due to a two-stage surgical treatment, where at the first stage of surgical treatment the osteotomy of the metacarpal bone is performed at the level of transition of the diaphysis to the pineal gland, and then using the monoplastic external fixation apparatus, the osteotomized fragment is distally distilled to the desired position, and the magnitude of the distraction is calculated from radiographs, after which the size of the autograft is calculated from the control radiographs, and at the second stage the formed diastasis is filled interposition of a bone autograft from the iliac crest and endoprosthetics of the metacarpophalangeal joint.

The figures depict:

FIG. 1 - A variant of the defect of the metacarpal bone.

FIG. 2 - Diagram of the implementation of the osteotomy of the metacarpal bone and the application of AVF.

FIG. 3 - Scheme of performing bone autoplasty of the metacarpal bone after distraction.

FIG. 4 - Scheme of implantation of the proximal component of the endoprosthesis.

The method is as follows.

Surgical treatment is carried out in two stages.

The first stage is performed under conduction anesthesia in the axillary region, the position of the patient on the back, the hand is laid on a side table. A tourniquet is applied to the upper third of the forearm. From the economical longitudinal skin incision, using the blunt and acute methods, subcutaneously expose the damaged metacarpal bone of the hand in the proximal third (Fig. 1) and perform transverse osteomy on the border of the proximal epiphysis and diaphysis with an oscillatory saw. Using an electric drill, one Kirschner transverse spoke is cantilevered into the metacarpal fragments proximal and distal to the osteotomy, and then fixed in the nodes of the mini-external fixation device, which is mounted on a threaded or threadless rod, for example, in the device according to patent RU 129380 (Device for external fixation of the metacarpal bones and phalanges of the fingers of the hand DG Nakonechny, DI Kutyanov, GV Kashulina Inventions Useful models: Official Bulletin of the Russian Agency for Patents and Trademarks Bulletin No. 18. - M ., 2012) (Fig. 2). Soft tissue is mobilized. Perform hemostasis and suture the wound in a line.

Distraction begins on the day after surgery, at a rate of up to 1 mm per day, until the osteotomized fragment of the metacarpal bone is brought into the distal direction to the desired position, taking into account the subsequent location of the components of the endoprosthesis, the amount of distraction is preliminarily calculated from radiographs. On the dressings assess the condition of the soft tissues. A control x-ray is performed immediately before the second stage of surgical treatment in order to clarify the position of the bone fragments and determine the amount of diastasis between them. According to the results of the control x-ray, the diastasis between the metacarpal bone fragments is measured to plan the size of the bone autograft.

The second stage of surgery is performed under combined anesthesia. The position of the patient on the back, the hand is laid on a side table.

Initially, a bone autograft of the required size is extracted from the iliac crest according to the method described in the patent for invention RU 2405469 (Method for two-stage lengthening of the stumps of the three-phalangeal fingers using a compression-distraction apparatus with axial holding of needles. L.A. Rodomanova, CB Valetova, D . G. Somov. Inventions. Utility models: Official Bulletin of the Russian Agency for Patents and Trademarks. peratsionnogo Planning depending on the size of diastasis between the fragments of the metacarpal bone. This technique allows you to reduce muscle trauma in the area of the transplant and significantly reduce the pain of the patient in the early postoperative period.

Next, a tourniquet is applied to the upper third of the forearm and the AVF is dismantled. An old postoperative scar with an increase in length in the distal direction provides access to the formed diastasis between the fragments of the metacarpal bone, where the bone autograft is placed (Fig. 3), which is fixed using a mini-plate and screws according to the standard technique. After performing metal osteosynthesis, the scar tissue in the area of the defect of the metacarpophalangeal joint is excised, the bone channel of the displaced fragment of the metacarpal bone is opened with an awl and endoporting of the metacarpophalangeal joint is performed according to the standard method using the manufacturer's recommendations (Fig. 4).

The practical implementation of the method is illustrated by the following clinical observation.

Patient N., 43 years old, DZ: Post-traumatic defect of the head 2 of the metacarpal bone of the right hand.

At the first stage of surgical treatment, an osteotomy of the 2 metacarpal bone of the right hand was performed, and the installation of AVF. The postoperative period was uneventful, 1 mm / day was performed, according to the stage radiographs, the diastasis was 3 cm.The distal fragment of the osteotomized metacarpal bone was reduced to the level of the anatomical position of the lost metacarpal head, taking into account the subsequent installation of the endoprosthesis. Conducted antianginal therapy, dressings with antiseptics. Skin wounds healed by primary intention. Sutures were removed on the 14th day.

At the second stage of surgical treatment, the AVF was dismantled; plastic surgery of the formed defect diastasis of the 2 metacarpal bone of the right hand with a bone autograft from the crest of the right iliac bone, an MOS mini-plate with angular stability of the screws, and endoprosthesis of the metacarpophalangeal joint with a prosthesis according to the manufacturer’s method. Immobilization with a permanent cast plaster bandage for 7 days, then removable splinting with individual exercises. After removal of the immobilization, a course of rehabilitation treatment (exercise therapy, FTL) was carried out. The postoperative period was uneventful, the treatment time was 7 weeks, and a good aesthetic and functional result was achieved. The patient is satisfied with the result of the treatment, got the opportunity to return to professional activities.

Thus, the method for eliminating a metacarpal defect with endoprosthetics of the metacarpophalangeal joint provides the possibility of prosthetics of the metacarpophalangeal joints of the hand with standard prostheses in the face of a pronounced metacarpal defect and shortens the treatment time for patients with this pathology.

Claims (1)

A method for eliminating a defect of the metacarpal bone with loss of its distal part and endoprosthetics of the metacarpophalangeal joint, comprising replacing the specified defect with a bone autograft from the iliac crest and endoprosthetics of the metacarpophalangeal joint, characterized in that at the first stage of surgical treatment an osteotomy is performed on its border diaphysis and proximal pineal gland, the imposition of a monoplastic apparatus of external fixation and the subsequent removal of the distal metacarpal fragment in the desired polo ix, wherein the distraction value calculated by the x-ray, and the second treatment stage is filled with formed diastasis between fragments metacarpal bone autograft from the iliac crest and carried endoprosthesis metacarpophalangeal joint by entering the leg proximal joint component stored medullary canal of the displaced fragment metacarpal bone.

Images