RU2833771C1 - Method for two-stage replacement of bone defect of interphalangeal joint of first toe in patients with osteomyelitis and charcot arthropathy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to pyo-orthopaedic and reconstructive surgery, and can be used for restoration of toe length with replacement of destructively destroyed 1 interphalangeal joint of foot. At the first stage, a surgical approach to an interphalangeal joint of the first toe is performed, followed by osteonecrectomy and bringing the toe into a physiological position. Then diafixation is carried out with pins with filling of defect with spacer from bone polymethylcrylate cement with antibiotic and wound closure is performed in layers. At the second stage, which is carried out in 6-8 weeks, diafixing pins and spacer from bone polymethylcrylate cement with antibiotic are removed from the defect area. Autograft is sampled from the pre-Achillary area of the calcaneal bone and inserted into the defect area, followed by pin osteosynthesis or compression screw followed by wound closure.

EFFECT: method provides reducing the risk of recurrent infection, improving the quality of the surgical intervention, reducing the surgical aggression, improving the graft restructuring and improving the patient's quality of life, after osteonecrectomy, due to lesion sanitation, removal of destructively changed tissues and bringing of finger into physiological position with diafixation with pins and filling of formed defect.

1 cl, 12 dwg, 1 ex

Description

The invention relates to medicine, in particular to purulent-septic and reconstructive surgery, and can be used to restore the bone structures of the first toe.

A method of surgical restoration of the defect of the phalanges of the first toe is known, which consists of distraction replacement of the defect with the Ilizarov KDA apparatus [V. Golyakhovsky, V. Frenkel. Manual on transosseous osteosynthesis using the Ilizarov method].

The method is carried out as follows:

An osteotomy of the stump of the proximal phalanx of the first toe is performed by passing two intersecting spokes through each fragment of the stump of the proximal phalanx of the first toe and mounting the rings of the external fixation apparatus on them, connected to each other by two rods. Subsequently, a gradual distraction build-up of the bone regenerate is performed by increasing the distance between the rings of the apparatus. When the length is restored and the regenerate is reconstructed, the apparatus is dismantled.

This method has the following disadvantages:

1) The small size of the finger phalanx stump makes it difficult to perform osteotomy and install an external fixation device.

2) If there is a soft tissue defect, it is not eliminated.

3) The lack of adequate blood supply to the finger stump increases the risk of recurrence of the osteomyelitic process.

4) A long period of time, which is necessary for the complete reconstruction of the regenerated bone stump and restoration of its mechanical strength.

A method is known for the restoration of the first toe in case of damage and its consequences (patent RU 2270628 published 27.02.2006. Bulletin 6), in which after sequester necrectomy a blood-supplied tissue complex is substituted, including a bone fragment cut out from the distal metaepiphyseal part of the tibia and a skin-fascial island flap from the dorsum of the foot on the distal vascular pedicle, a rotation of 180° is performed, after which the bone fragment is fixed telescopically with pins to the stump of the proximal phalanx of the first toe, which is wrapped in a skin-fascial flap and then sutured along the perimeter to the edge of the defect of the integumentary tissues, after which the foot is fixed in a 90° position. The known method allows to increase the reliability and quality of surgical intervention; reduce the number of complications, restore the supporting function of the limb and improve the patient's quality of life, apply early patient activation, reduce treatment time, which ensures rapid social and labor rehabilitation of victims.

The disadvantage of this method is the volume of the intervention, the involvement of the anterior tibial artery and its exclusion from further blood supply to the foot, requiring greater surgical aggression and the existing risks of thrombosis of the feeding artery. A method is known (Golyakhovsky V., Frenkel V. Manual of transosseous osteosynthesis by the Ilizarov method. St. Petersburg, 1999. - 269 p.) for the restoration of the 1st toe in case of damage and their consequences, consisting of directed osteogenesis using the KDA G.A. Ilizarov apparatus.

No closest analogues from the technical field have been identified.

The technical result achieved by using the proposed invention is to ensure the restoration of the length of the first toe by performing a two-stage bone grafting of the defect area, which ensures anatomical restoration of the proximal phalanx of the first toe, reduces the number of complications, restores the support capacity of the lower limb, improves the patient's quality of life, minimizes the risk of recurrence of infection at the first stage, improves the restructuring of the bone autograft due to the active membrane, simultaneously fills the bone defect, minimizes surgical aggression and leaves adjacent segments intact.

The said technical result is achieved by the method consisting in performing osteonecrectomy at the first stage and determining the size of the bone defect, restoring the length of the first toe and fixing it with pins in the normocorrection position, followed by filling the defect with an antibacterial spacer, which allows for the formation of an active membrane in the bone defect zone and the release of an antibiotic from the spacer in the zone of the planned bone grafting and one-stage restoration of the toe length, preventing tissue retraction in the future. The second stage is performed after 6-8 weeks. At the second stage, the spacer is removed from the first toe, an autograft is taken from the periachillary zone of the same foot, the graft is processed to a size comparable to the size of the defect, the autograft is installed in the defect of the first toe with arthrodesis of the interphalangeal joint with a screw or pins.

The method is carried out as follows: a diagram illustrating the step-by-step execution of the operation is shown in Fig. 1-12

1. Fig. 1 and Fig. 2 show the patient's radiographs upon presentation

2. Fig. 2 shows the patient's radiographs upon presentation

3. Fig. 3 - photo of the patient's foot

4. Fig. 4 - EOP image after removal of destructively altered tissues, restoration of the length of the first finger and diafixation with pins in the normocorrection position.

5. Fig. 5 - EOP image of a finger after filling the defect with an antibacterial spacer.

6. Fig. 6 - stage of replacement of the defect of the first finger with a bone autograft after removal of the spacer.

7. Fig. 7 and Fig. 8 - EOP control after performing arthrodesis with a screw.

8. Fig. 9 and Fig. 10 - X-ray control after 1 year.

9. Fig. 11 and Fig. 12 - photo of the finger after 1 year.

Thus, the proposed method, by restoring the length of the first finger by performing a two-stage bone grafting of the defect area, allows for the stated technical result: it reduces the number of complications, restores the support ability of the lower limb, improves the patient's quality of life, minimizes the risk of recurrence of infection at the first stage, improves the restructuring of the bone autograft, minimizes surgical aggression and leaves adjacent segments intact.

The method is illustrated by a clinical example:

Patient P., 52 years old. Two months before the visit, he noted the appearance of foot edema, an increase in body temperature to subfebrile numbers. He denied injuries. After examination and radiography of the foot (Figs. 1-3), a course of conservative therapy and unloading of the affected foot, the first stage of reconstructive intervention was performed as planned - removal of destructively changed tissues, restoration of the length of the first toe and filling the cavity with an antibacterial spacer under the control of an electron-optical converter (Figs. 4-5), healing was carried out by primary intention, 2 months later the second stage of reconstructive intervention was performed with removal of the spacer and plastic surgery of the defect with a bone autograft from the pre-Achilles zone (Figs. 6-8). Arthrodesis with a screw. Control examination 1 year after the intervention (Figs. 9-12).

Claims (1)

A two-stage method for replacing a defect in the interphalangeal joint of the first toe, characterized by the fact that at the first stage, surgical access to the interphalangeal joint of the first toe is performed, followed by osteonecrectomy and bringing the toe into a physiological position, then diafixation with pins is performed with filling the defect with a spacer made of bone polymethylacrylate cement with an antibiotic and layer-by-layer suturing of the wound is performed; at the second stage, which is performed after 6-8 weeks, diafixing pins and a spacer made of bone polymethylacrylate cement with an antibiotic are removed from the defect area, an autograft is taken from the pre-Achilles zone of the calcaneus and installed in the defect area with subsequent osteosynthesis with pins or a compression screw, followed by suturing of the wound.