RU2816622C1 - Method for surgical treatment of pseudoarthrosis of external condyle of humerus - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.

SUBSTANCE: invention can be used for surgical treatment of pseudoarthrosis of external condyle of humerus in children. Surgical approach to the false joint is performed. Cicatrical tissue of the false joint is excised, and the surface of the bone fragment and humerus is exposed to bleeding. Forearm is turned relative to the shoulder by aligning the axis of the shoulder and the forearm; the fragment is set in an anatomically correct position. Crosswise dimension of diastasis between fragment and humerus is measured. Autograft is formed; for this purpose, a fragment is taken from the diaphysis of the fibular bone of the patient, which is twice as long as the transverse dimension of the diastasis; the fragment is dissected into two parts of an unequal length. Autograft is laid in the defect between the metaphysis of the humerus and the fragment. Long fragment is laid lateral to the short fragment; the autografts are fixed with pins delivered through the fragment into the humerus. Extremity is immobilized with an external fixation apparatus. At that, parts of fragment of fibular bone are processed along side surface, creating plane, providing contact of two parts of the fragment with planes and connecting parts of the fragment with a lavsan tape. One part of the fibular fragment is 15 mm long, the second part is 20 mm long.

EFFECT: method provides filling the bone defect, achieving fusion of the false joint, correcting the axis of the upper extremity, creation of favorable anatomical conditions for recovery of elbow joint function and elimination of posttraumatic neuritis due to elimination of false joint and recovery of upper extremity axis and elbow joint function.

3 cl, 7 dwg, 2 ex

Description

Field of technology.

The invention relates to medicine, namely to traumatology and orthopedics, and is intended to eliminate false joints, restore the axis of the upper limb and the function of the elbow joint, after an old fracture of the lateral condyle of the humerus with bone deficiency.

State of the art.

Various surgical methods are known from the prior art for eliminating the false joint and replacing the defect in case of fractures of the condyle of the humerus.

To replace bone defects, a wide range of methods are used, such as free autograft transplantation, non-free bone grafting, autograft transplantation on a vascular pedicle, installation of metal, polymer, composite implants, allografts, non-free bone tissue transplantation and the formation of new bone tissue according to G.A. Ilizarov and combined methods. (FILIPPOV V.V. Vascularized periosteal-cortical autografts in reconstructive surgery of the extremities. Abstract of thesis. Doctor of Medical Sciences, M., 2013; Conservative treatment of false joints of long tubular bones. - Chisinau, 1990, p. 28-58. KORKHOV V.V. Surgical treatment of false joints. - M., 1966, p. 38-46. MULLER M. E. et al. Guide to internal osteosynthesis. - M.: Medicine, 1996, p. 721.).

The most biological way to replace bone defects is the method of distraction osteogenesis according to G.A. Ilizarov (Ilizarov G. A., Shved S. I., Martel I. I. Transosseous osteosynthesis of severe open fractures of the humerus: methodological recommendations / Ministry of Health of the RSFSR; All-Russian Scientific Center "VTO". Kurgan, 1990. 29 p.), when the defect completely replaced by newly formed bone tissue.

However, the disadvantage of this method is the need for long-term distraction of the bone fragment, since the regenerate is formed at a rate of 1 to 2 mm per day. In this regard, currently, as a rule, methods are used that include open reposition of the fragment and internal fixation, for this purpose an incision is made in the area of the pseudarthrosis, excision of scar tissue in the area of the pseudarthrosis, treatment of the surfaces of the bone and fragment until “bloody dew”, comparison of the fragment with bone and fixation using screws (MULLER M.E. Guide to internal osteosynthesis - Springer-Verlag, 1996, p. 726).

There is a known method of surgical treatment of a fracture of the condyle of the humerus in children and adolescents (patent RU 2593230). The method uses closed reduction and external transosseous fixation with an external fixation device. Two parallel knitting needles with thrust pads are passed in the frontal plane through the condyles of the humerus in the opposite direction, and they are fixed using the external support of the apparatus. One intraosseous Shants rod is passed along the outer lateral surface of the lower third of the shoulder and fixed to the support through a bracket with a threaded hole.

However, this method does not allow for fusion of the fragment with the bone in case of an old fracture and the presence of a false composition, it does not allow processing the ends of the bone and replenishing the bone defect in case of bone tissue deficiency.

There is a known method for restoring the function of the elbow joint with pseudarthrosis of the condyle of the humerus (RU 2521536). The first stage of the method consists of closed reposition of fragments of the humeral condyle and tunneling of the pseudarthrosis zone. Closed osteosynthesis of the humerus using the Ilizarov apparatus ^TM . Wires with thrust pads are passed through the fragment of the condyle of the humerus. The spokes are secured to the support of the apparatus. The second stage of treatment is carried out after dismantling the device on the shoulder and consists of performing a wedge-shaped osteotomy of the olecranon process of the ulna and osteosynthesis of the shoulder and forearm using the Ilizarov apparatus.

However, this method involves long-term treatment, in two stages, and does not make it possible to fill the bone defect in case of bone tissue deficiency or restore the axis of the limb.

These methods are not applicable in the treatment of old false joints of the head of the condyle of the humerus with displacement, when trophic disorders of the bone fragment develop and there is a significant curvature of the limb axis with an angle between the axis of the shoulder and forearm from 30 to 40 degrees.

There is a known method for the treatment of false joints of the head of the condyle of the humerus (RU 97111424), which consists of mechanical fixation of a broken fragment of the head of the condyle of the humerus to its anatomical bone bed. The plane of the pseudarthrosis is covered with a bone autograft cut from the distal part of the humerus with the brachioradialis muscle with vessels and nerves attached to it, and the fragment of the head of the condyle of the humerus is fixed to the parent bed using a screw.

There is also a known method for the treatment of false joints (patent RU 2158114), which consists in the treatment of bone fragments, osteosynthesis, plastic surgery of the false joint with a bone graft cut from the distal humerus with the brachioradialis muscle attached to it with vessels and nerves.

These methods increase the risk of complications and slow down the consolidation of the fragment and bone, since the bone graft is taken from the distal part of the damaged humerus with a muscle area, in combination with a surgical incision on the same limb, such manipulations lead to disruption of the blood supply to the shoulder and disrupt tissue trophism and the ability to regenerate bone. Making incisions in the skin, muscles, blood vessels, and the damaged limb increases the duration of consolidation of the autograft and bone fragments; more time is required to restore the function of the limb.

In pseudarthrosis that develops after ununited fractures with displacement, without impaired articulation with the head of the radius, the central part of the trochlea and the outer part of the condyle lag behind in development, undergo resorption, a defect in the bone tissue of the epimetaphysis is formed, the ulnar fossa disappears in the condyle, the forearm is set in a position of external deviation at an angle from 30 to 40 ⁰ (see Fig. 1), post-traumatic late neuritis of the ulnar nerve develops due to overextension and compression of it towards the internal epicondyle, secondary contracture of the joint develops, and osteoporosis of the unfused fragment is formed.

There is a known method for the treatment of ununited fractures and false joints of long bones (RU 2359632). In the method, scar tissue is removed at the junction of fragments, an autograft is taken from the iliac crest using an osteoperforator, and the resulting defect at the junction of fragments is filled with spongy bone tissue taken from the iliac crest.

However, a graft from the ilium does not have sufficient strength and supportability, for example, in comparison with a graft taken from the diaphysis of the fibula, and does not have the necessary mechanical properties inherent in a graft with cortical plates. The graft requires pre-modeling and processing before installation to the required geometric shape. Lack of compression in the area of a non-union fracture or pseudarthrosis can lead to an unsatisfactory treatment outcome.

The problem is that the known methods do not allow effective treatment of pseudoarthrosis of the lateral condyle of the humerus, simultaneously eliminating the false joint, restoring the axis of the upper limb and the function of the elbow joint, after an old fracture of the lateral condyle of the humerus with bone deficiency.

It is necessary to expand the arsenal of methods for surgical reconstruction of the humerus, allowing for consolidation of the area of pseudarthrosis with subsequent restoration of the function of the elbow joint, the axis of the limb, and to avoid ulnar nerve neuritis.

The essence of the technical solution.

The technical result consists in eliminating the pseudarthrosis, restoring the axis of the upper limb and the function of the elbow joint after an old fracture of the lateral condyle of the humerus with bone deficiency. The method provides filling of the bone defect, achieving fusion of the pseudarthrosis, correcting the axis of the upper limb, creating favorable anatomical conditions for restoring the function of the elbow joint and eliminating post-traumatic neuritis.

The technical result is achieved by the fact that in the method of surgical treatment of pseudarthrosis of the lateral condyle of the humerus in children, surgical access to the pseudarthrosis is performed, scar tissue of the pseudarthrosis area is excised, the surface of the bone fragment and humerus is exposed until bleeding, the forearm is rotated relative to the shoulder, aligning the axis shoulder and forearm, place the fragment in an anatomically correct position, measure the transverse size of the diastasis between the fragment and the humerus, form an autograft, for this purpose a fragment is taken from the diaphysis of the patient's fibula along a length twice the transverse size of the diastase, the fragment is cut into two unequal parts longer than the size, the autograft is placed in the defect between the metaphysis of the humerus and the fragment, the long fragment is placed lateral to the short fragment, the autografts are fixed with knitting needles passed through the fragment into the humerus, and the limb is immobilized with an external fixation device.

The method is illustrated with graphic materials:

Figure 1 - X-ray images of the upper limb, pseudarthrosis of the external condyle of the humerus is visible, when correcting the axis of the limb, the size of the formed bone defect is visible.

Figure 2 - Diagram illustrating the stages of the operation: on the left, the limb bones before surgery, on the right, the limb bones after correcting the axis (autograft is shown), on the right, the limb bones after installation of the autograft;

Figure 3 - X-rays of the upper limb after installation of the autograft, visible wires, replacement of the bone defect with grafts, fixation with four wires;

Figure 4 - Radiographs of the upper limb after treatment.

Figure 5 - Radiographs of the upper limb, patient U.U., born in 2012. pseudoarthrosis of the lateral condyle of the humerus, pseudarthrosis of the humerus with a bone defect;

Fig.6 - Photo of patient U.U., born in 2012, after treatment, radiographs of the elbow joint, the result is fusion of the pseudarthrosis; the arm axis is correct, the joint function is “good”;

Figure 7 - X-rays of the upper limb of patient M.S. Born 2011 after treatment.

The graphic materials indicate:

1 - humerus;

2 - bones of the forearm;

3 - fragment;

4 - part of a fragment of the fibula;

5 - part of a fragment of the fibula;

6 - diastasis;

7 - knitting needles.

Implementation of a method for surgical treatment of pseudoartosis of the lateral humeral condyle.

General anesthesia is performed. Under sterile conditions, a skin incision is made using external access, the area of the pseudarthrosis is exposed, and surgical access to the pseudarthrosis is performed. Excision of scar tissue from the area of the pseudarthrosis is performed. Scars are excised, fibrous tissue, the bone wound of the metaphysis and unfused fragment 3 is thoroughly cleaned of fibrous deposits. The surfaces of bone fragment 3 and humerus 1 are exposed until bleeding occurs. The forearm is rotated relative to the shoulder, aligning the axis of the shoulder and forearm. When correcting the axis of the limb, a cavity is formed - diastasis 6, indicating a lack of bone tissue.

Fragment 3 is placed in the anatomically correct position to ensure the function of the elbow joint. The transverse size of diastasis 6 between fragment 3 and humerus 1 is measured.

An autograft is formed to fill the bone tissue defect; for this purpose, a fragment is taken from the diaphysis of the patient's fibula with a length twice the transverse size of the diastasis; the fragment is cut into two parts 4 and 5 of unequal length. The fibula allows the formation of an autograft that is resistant to longitudinal load. The shape of the diaphysis of the fibula is close to cylindrical, therefore, to fill the defect, it is necessary to use two fragments of different lengths 4 and 5. The fragment is taken subperiosteally from the diaphysis of the patient's fibula. The size of the autograft corresponds to the size of the diastasis determined during the operation to eliminate the valgus deviation of the forearm - cubitus valgus. As a rule, fragments 4 and 5 with a length of 5 to 20 mm are required.

The autograft is placed in diastasis 6 between the metaphysis of the humerus 1 and fragment 3, the long fragment 5 is placed lateral to the short fragment 4.

After replacing the bone defect of condylus humeri, fixation of the autograft and fragment 3 is carried out with 7 knitting needles, followed by immobilization to achieve fusion with an external fixation device, Ilizarov ^type .

The autograft is fixed with two knitting needles passed through the fragment into humerus bone 1, and two knitting needles 7 connect fragment 3 and bone 1.

This operation eliminates the defect in the bone tissue of the condyle, leads to fusion of the false joint, restores the limb axis and normal anatomical relationships of the shoulder and forearm, creates conditions for support of the olecranon during extension movement, and the function of the elbow joint.

In one of the embodiments of the method, when forming an autograft, fragments 4 and 5 of the fibula, two parts, are processed along the lateral surface creating a plane for mating, contact of two parts 4 and 5 of the fragment is ensured by planes, and parts 4 and 5 of the fragment are connected with Mylar tape, thus thereby forming an autograft consisting of two parts. This makes it possible to create a single bone block for transplantation, and ensures mutual mobility of parts 4 and 5 of the autograft, which allows you to adjust its position in the wound, ensuring filling of the defect in the most optimal way, and ensuring the convenience of installing the autograft in the wound. Treatment of the side surface allows the parts of the fragment to be leaned against each other and does not allow them to rotate relative to each other in diastasis, when fixed with knitting needles.

Clinical example. Patient U.U., born in 2012. (Fig.3;4;5)

General anesthesia is performed. Under sterile conditions, a skin incision is made using external access, the area of the pseudarthrosis is exposed, and surgical access to the pseudarthrosis is performed. Excision of scar tissue from the area of the pseudarthrosis is performed. Scars are excised, fibrous tissue, the bone wound of the metaphysis and unfused fragment is thoroughly cleaned of fibrous layers. The surfaces of the bone fragment and humerus are exposed until bleeding occurs. The forearm is rotated relative to the shoulder, aligning the axis of the shoulder and forearm. When correcting the axis of the limb, a cavity is formed - diastasis, indicating a lack of bone tissue.

The fragment is placed in the anatomically correct position to ensure the function of the elbow joint. The transverse size of the diastasis between the fragment and the humerus is measured.

An autograft is formed to fill the bone tissue defect; for this purpose, a fragment is taken from the diaphysis of the patient's fibula along a length twice the transverse size of the diastasis; the fragment is cut into two parts of unequal length. The fibula allows the formation of a graft resistant to longitudinal load. The shape of the diaphysis of the fibula is close to cylindrical, so it is necessary to use two fragments of different lengths. The fragment is taken subperiosteally from the diaphysis of the patient's fibula. The length of the autograft corresponds to the size of the diastasis determined during surgery to eliminate the valgus deviation of the forearm - cubitus valgus. Typically, fragments of 15 to 20 mm in length are required.

A clinical example (Fig. 7) showing the fusion of grafts at the beginning from the side of the metaphysis, and their fusion with a fragment of the SMPC after the application of the Ilizarov apparatus. Patient M.S. Born in 2011, he was admitted with a diagnosis of pseudarthrosis of the hip joint, condition after bone grafting surgery, fixed with wires. An x-ray taken on the day of admission reveals fusion of the grafts on the side of the metaphysis and their weak consolidation with the SMPC fragment.

The operation has been performed.

General anesthesia is performed. Under sterile conditions, a skin incision is made using external access, the area of the pseudarthrosis is exposed, and surgical access to the pseudarthrosis is performed. Excision of scar tissue from the area of the pseudarthrosis is performed. Scars are excised, fibrous tissue, the bone wound of the metaphysis and unfused fragment is thoroughly cleaned of fibrous layers. The surfaces of the bone fragment and humerus are exposed until bleeding occurs. The forearm is rotated relative to the shoulder, aligning the axis of the shoulder and forearm. When correcting the axis of the limb, a cavity is formed - diastasis, indicating a lack of bone tissue.

The fragment is placed in the anatomically correct position to ensure the function of the elbow joint. The transverse size of the diastasis between the fragment and the humerus is measured.

An autograft is formed to fill the bone tissue defect; for this purpose, a fragment is taken from the diaphysis of the patient's fibula along a length twice the transverse size of the diastasis; the fragment is cut into two parts of unequal length. The fibula allows the formation of a graft resistant to longitudinal load. The shape of the diaphysis of the fibula is close to cylindrical, so it is necessary to use two fragments of different lengths. The fragment is taken subperiosteally from the diaphysis of the patient's fibula. The length of the autograft corresponds to the size of the diastasis determined during surgery to eliminate the valgus deviation of the forearm - cubitus valgus. Fragments of 15 mm and 20 mm are required.

Surgery technique: Skin incision using lateral approach. The fibrous, scar tissue between the metaphysis and the head of the condyle and metaphysis is dissected and excised. A site is prepared on the metaphysis for placement of the graft. The arm on the operating table is extended, removed from the valgus position, at this moment a diastasis is formed between the metaphysis and the head of the condyle. The size of diastasis is measured. Taking a bone graft from the fibula: in the area of the middle-lower third of the leg, after a skin incision, moving the muscles subperiosteally, using a Gigli saw, a graft of the required length is taken. Layer-by-layer sutures are applied, the suture is on the skin. The graft is cut into 2 halves. One is longer than the other. When placing grafts, one must take into account the physiological angle between the diaphysis and the head of the condyle. To do this, the joint is given a bent position (at an angle of 130-140°). The placed grafts are fixed, initially it is possible to carry them through bone canals, always through fragments. Another one or two needles are passed from the head of the condyle to the block (landmark of the internal epicondyle). This wire is axial in cases of application of the Ilizarov apparatus. In cases where the stability of fixation with knitting needles is considered sufficient, external immobilization is carried out with a plaster splint.

The autograft is placed in the defect between the metaphysis of the humerus and the fragment, the long fragment is placed lateral to the short fragment.

After replacing the bone defect of condylus humeri, fixation of the autograft and fragment is carried out with knitting needles, followed by immobilization to achieve fusion with an external fixation device, Ilizarov ^type .

The autograft is fixed with two knitting needles passed through the fragment into the humerus, and two knitting needles connect the fragment and the bone

Closed application of the device, assembled from one proximal and ½ distal ring. After 2 months and 17 days, an x-ray revealed a union and the device was removed (Fig. 7).

Thus, the method allows you to expand the arsenal of methods for surgical reconstruction of the humerus.

Claims (3)

1. A method of surgical treatment of pseudarthrosis of the lateral condyle of the humerus in children, characterized by the fact that surgical access to the pseudarthrosis is performed, scar tissue of the pseudarthrosis area is excised, the surface of the bone fragment and humerus is exposed until bleeding, the forearm is rotated relative to the shoulder, aligning the axis shoulder and forearm, place the fragment in an anatomically correct position, measure the transverse size of the diastasis between the fragment and the humerus, form an autograft, for this purpose a fragment is taken from the diaphysis of the patient's fibula, the length of which is twice the transverse size of the diastasis, the fragment is cut into two parts of unequal length, the autograft is placed in the defect between the metaphysis of the humerus and the fragment, the long fragment is placed lateral to the short fragment, the autografts are fixed with knitting needles passed through the fragment into the humerus, and the limb is immobilized with an external fixation apparatus. 2. The method according to claim 1, characterized in that parts of the fragment of the fibula are processed along the lateral surface, creating a plane, contact of the two parts of the fragment is ensured by planes and the parts of the fragment are connected with Mylar tape. 3. The method according to claim 1, characterized in that one part of the fibula fragment is made 15 mm long, the second part is 20 mm long.