The method of instrumental correction of kyphosis and fixation of the spine in tuberculous spondylitis in children

 

The invention relates to medicine, namely to surgical vertebrology, and can be used to correct the kyphotic deformity and fixation of the spine in tuberculous spondylitis in children. The invention provides an increase in the size correction of kyphosis and stable fixation of the spine in terms of the achieved correction, especially at the most coarse thoracic kyphosis tubercular etiology in children. The method consists in the fact that after a radical reconstruction of the spine hold it back instrumental fixation of the two contractors with the supporting hooks also use wire pull, which together with the two contractors with the supporting hooks are installed in two stages: in the first stage, first on one side of the spine, and then another set on the upper knee of the kyphosis of the upper supporting hook on the transverse process in children older than 5 years and on the arc of the spine in young children, and an intermediate hook under the arch to create the “claws”; then on the lower knee kyphosis conducting wire traction around the arches of the vertebrae; in the second stage mounted on the upper knee of the kyphosis support hooks enter the core of the contractor, opinionist; then over the studs on the lower knee kyphosis twist wire thrust, bringing with it the rods to the spine to eliminate strain; and then insert the rod into the bottom of the supporting hook, the sting of which is injected into the pre-prepared subliminares bed, and fix the rod support hook end key. The core of the contractor pre-model for physiological contour of the spine. In children younger wire traction spin so that the direction of twisting in the first round of rotation was directed to the rod: for structures installed to the right of the spinous processes, this corresponds to a twisting clockwise and to the left, counterclockwise. 2 C.p. f-crystals, 6 ill.

The invention relates to medicine, namely to surgical vertebrology, and can be used to correct the kyphotic deformity and fixation of the spine in tuberculous spondylitis in children.

For tuberculous spondylitis in children is characterized by extensive destruction of the vertebral bodies, leading to instability of the spine and the formation of a rough rigid angular kyphosis. Radical the processes of the spinal cord and anterior cervical fusion (Hodgson, A. R., Stock F. E et al., 1956, 1960, Kovalenko, D., Matias, A. E., 1983, Kovalenko, K. N., 1990), is the basis of modern surgical treatment of tuberculous spondylitis, but provides minimal correction of kyphosis (mean correction does not exceed 5°) and requires prolonged external fixation in plaster crib or corset to create conditions for the formation of fusion.

The known method of instrumental correction of kyphosis and fixation of the spine in tuberculous spondylitis, based on the use of submersible rear beam structures such as CD and TSRH with transpedicular and hard hook fixation [Moon M. S. et al., Posterior instrumentation and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spines // Spine. - 1995. - No. 17. - P. 1910-1916; Moon, M. S. Tuberculosis of the spine: controversies and a new challenge // Spine. - 1997. No. 15. - P. 1791-1797]. Its disadvantage is the impossibility of the use of children under the age of 10 years due to the size of the supporting hooks and screws, on the one hand, the superior arc characteristics of child vertebra, and on the other damaging children zone interstitial cartilage and potentially dangerous for the development of stenosis of the spinal canal.

In the treatment of tuberculous spondylitis in children also used the method of correction of kyphosis and fixation of the spine using sublaminar ment with anterior vascularised rib grafts, posterior osteotomies and fusion // J Bone Joint Surg. - 1990. - V. 72 - B. - P. 686-693] where polysegmental traction is the arc of the vertebrae in the direction from front to back, and the extra mobility of the spine is achieved by resection of the arc of the vertebra at the apex of the kyphosis. The disadvantages of the method are due to: 1) one-pointedness of corrective efforts, existing only perpendicular to the axis of the spine, and 2) the danger of eruption of wire rods, especially in the most intense end supports. In the treatment of tuberculous spondylitis in children also use distractor Harrington [Bakin M. The value of the additional fixation of the spine distractor Harrington in surgical treatment of spondylitis in children // Traumat. The orthopedist. Russia. - 1995. No. 6. - S. 20-24], which ensures the fixation of the spine, but corrects deformation only in the mobile lumbar-thoracic spine within 10-15° and ineffective in rigid thoracic.

The prototype of the present invention is a method of correction of kyphosis and fixation of the spine in tuberculous spondylitis in children, based on the use of compression rods [Mushkin, A. J., Kovalenko, K. N., Bakin M. Correction of kyphosis in tuberculous spondylitis in dyavola dvuhkrjuchkovaja contractors, set back from the fixation end of the supporting hooks on the arches of the vertebrae. The correction is performed by shortening the length of the posterior columns of the spine at a voltage of design at the most coarse thoracic kyphosis additionally resetinput arc apical vertebra. The method allows to achieve a correction of 30°, its disadvantages are: 1) a small number of control arcs (two on each side), it is potentially dangerous when large corrective effort, 2) the preservation potential mobility of the vertebral segments within the zone instrumental fixation, 3) axial orientation corrective efforts, acting only along the metal rod.

The objective of the invention is to increase the magnitude of correction of kyphosis and stable fixation of the spine in terms of the achieved correction, especially at the most coarse thoracic kyphosis tubercular etiology in children.

The objective of the invention is due to the fact that the correction of kyphosis and fixation of the spine is achieved by the use of structures with multi-directional detent three anchor hooks and sublaminar wire rods acting simultaneously along and perpendicular to the axis of the spine and providing what is stabilization of the spine in the corrected position.

List of graphic figures:

Fig.1 - install the supporting hooks on the upper knee kyphosis: upper supporting hook on the transverse process (a) or supraliminal (b, g); intermediate anchor hook, forming a pincer - subliminale ();

Fig.2 - conducting wire around the arc;

Fig.3 - the formation of an upper reference "claws";

Fig.4 - direction twisting wire: a - correct b - incorrect (explanation in the text);

Fig.5 is a diagram of a radical reconstruction of the spinal fixation multisupport contractor with a wire thrust, and is the initial state; b - shaped upper supporting "the claw", the voltage of the wire rods leads to the effect of "leverage"; - final state commit, is additionally held back fusion. On the vector diagram (b) shows the direction of the action of forces applied to the spine for areas fixation with tension structures;

Fig.6 - clinical sample. Patient Z. R., age 5, tuberculous spondylitis T6-9; and - before the operation, b - after the operation.

The method is as follows.

Upon completion of the radical reconstructive phase of the operation, the patient from a position on one side is translated into position on his stomach. The implementation of the SPO the positive phase. From the rear of the median access the back surface of the arches of the vertebrae bare bone raspatory within the zone instrumental fixation, and the upper bearing vertebrae also naked and transverse processes. The supporting structural members fixed first on one side of the spine, then contralateral, while avoiding full segmental violations of the posterior ligamentous support complex supporting elements (hooks, wire) symmetrically from two sides do not set.

The upper supporting hook set in children older than 5 years on the transverse process, and the younger children on an arch of a vertebra. Intermediate supporting hook, forming a claw, fixed under the arc (sublaminar). When installing the upper hook on the transverse process, the bed for him to prepare curved rasputia, separating the fiber rib-transverse ligament (Fig.1, a). When forming superluminova bed possible technical difficulties associated with-imbricate arrangement of arcs of the thoracic vertebrae. In this case laminectomies pliers or narrow osteotome U-shape resetinput the lower edge of the overlying arc, which facilitates the subsequent installation of the hook (Fig.1B, g), (Fig.3). The formation of the su is Fig.1, b).

On the vertebrae, located at 1 and/or 2 more cranial segment lower bearing of the arc, creating a pull wire, for which around their arcs conducting metal wire (Fig.2) what pre-laminectomy and pliers Kerrison'resetinput at these levels supraspinatus, mistou and yellow ligament (method Lugue).

Curved rasputia or areobtained the arc of the lower bearing vertebrae form subliminary Lodge, however, the lower supporting hooks at this stage they are not set.

When coarse kyphosis greater than 55 to 60° for additional mobility of the spine, after setting of the reference elements resetinput arc apical vertebra with articular processes.

2. Stage instrumental correction and fixation. In installed on the upper knee of the kyphosis support hooks enter the step portion of the rod of the contractor, pre-otmodelerpage by physiological contour of the spine, which are planned to be reconstructed in the course of the operation. The hooks closer to their tilting and jamming on the rod, which leads to the formation of the combined upper support - "claws" (Fig.3). The formation of the "claws" of differently jamming its forming hooks allows predot kyphosis above the bars twist the wire pull (for a few rods start with the closest to the apex of the kyphosis). The direction of twisting of the wire over the rod does not matter in older children and adults. In children younger twisting is carried out so that the direction of the wire when the first round of the curl was directed to the rod: for structures installed to the right of the spinous processes, this corresponds to a twisting clockwise (Fig.4A), the left - counterclockwise. Otherwise twisting the wire leading to incision in the midline at the upper edge of the arc and in the external part at the bottom edge of the arc, which leads to its eruption (Fig.4, b).

When tightening the wire is formed three-point corrective design, in which the role of a single upper support performs fixed "claw", and the lower arc with a wire thrust, middle - top of the kyphosis. The force applied to the spine at the upper and lower bearings, directed from front to back, and to the middle - back to front (Fig.5). When tightening the wire rod, the lower end of the rod is gradually approaching the spine, which is accompanied by reduction of the strain.

On the lower end of the rod holder put on the bottom of the supporting hook, the sting of which is at the maximum voltage wire plug. T. O. design is tense in the horizontal plane. For additional correction of deformation and stresses of the structure along the vertical axis dislocation produce the offset anchor hooks "claws": Caudalie shift first the lower, then upper hook up to their jamming in the tensioned state.

In that case, if during the preparatory phase was resected arc apical vertebra, the voltage metal observed reduction of the diastasis between the arches of the vertebrae, up to their complete contact. The surgery is completed the back bone of plastic stabilization, stacking bone fragments on the rear arches of the vertebrae along the entire zone instrumental fixation. The wound is sutured tightly, leaving passive drainage.

Clinical validation of the method. Since 1998, the radical reconstruction of the spine in combination with the inventive method of instrumental correction of kyphosis and fixation of the spine held in the Department of surgery of osteoarticular tuberculosis in children and adolescents Spbniif 9 children aged 1.5 to 5 years with tuberculous spondylitis of the thoracic spine (T4-T11), complicated rigidly is under the arc of the apical vertebra. The maximum correction was 47° and was the highest in comparison with previously used methods. Thus, children with the most serious deformations obtained cosmetically and functionally significant correction. As an illustration, here is the following clinical example:

Patient Z. R., age 5, case history No. 623, enrolled in the Department of surgery of osteoarticular tuberculosis in children and adolescents Spbniif 15.06.2001. Primary diagnosis of Tuberculous spondylitis T6-9. Complications: paravertebral abscesses, spinal instability with angular kyphosis 69° (Fig.6A).

Operation 26.06.2001: Extended radical reconstruction of the spine T5-9 with rear instrumental correction of kyphosis and fixation of the spine mnogomernymi contractors with wire rods and posterior spinal fusion. The operation is carried out in two stages: in the first of transthoracic vneplevralny access to the right made a radical reconstruction of the spine T5-9. Then the patient was transferred to the position on his stomach.

Rear middle access from T3 to T12. Resection of arc T8 vertebra with education magdoskova diastasis 1 see Set supporting elements:

left: the anchor hooks - superlumin inerno T11 and L1;

the pull wire on the T5.

In the supporting elements are inserted and tense two contractor, with decreased maguikay diastasis T7-9. Along the structures laid fragments of cancellous autologous and cortical allocate. Layer-by-layer suture wounds, leaving graduates.

On the x-ray after surgery (Fig.6, b) - gentle kyphotic arc 22°, the corresponding physiological chest kyphosis. The total value of the correction - 47°. The child was transferred to a vertical position after 1 month after surgery, after 2 months prescribed under the supervision of the clinic to continue anti-TB chemotherapy. X-ray control after 6 months of operation - the preservation of the achieved results in full, freely walks, subjective complaints there.

Claims

1. The method of instrumental correction of kyphosis and fixation of the spine in tuberculous spondylitis in children, namely, after the radical reconstruction of the spine are two of the contractor with supporting hooks, characterized in that also use the wire traction, which together with the two contractors with the supporting hooks set in two stages: the first stage SN is rucak on the transverse process in children older than 5 years and on the arc of the spine in young children, and intermediate the hook under the arch to create the “claws”; then lower the knee kyphosis conducting wire traction around the arches of the vertebrae; in the second stage mounted on the upper knee of the kyphosis support hooks enter the core of the contractor, anchor hooks closer to their wedge, forming support the “claw” to prevent vertical displacement of the rod; then the rods on the lower knee kyphosis twist wire thrust, bringing with it the rods to the spine to eliminate strain; then insert the rod into the bottom of the supporting hook, the sting of which is injected into the pre-prepared subliminares bed, and fix the rod support hook end of the key.

2. The method according to p. 1, characterized in that the rod of the contractor pre-model for physiological contour of the spine.

3. The method according to p. 1, characterized in that the younger children of the wire traction spin so that the direction of twisting in the first round of rotation was directed to the rod: for structures installed to the right of the spinous processes, this corresponds to twisting clockwise and to the left, counterclockwise.



 

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FIELD: medicine, orthopedics, traumatology.

SUBSTANCE: one should isolate and dissect the tendons of anterior tibial and long fibular muscles to dissect the tendon of posterior tibial muscle against the site of fixation and direct it towards plantar rear area in front of internal ankle through the tunnel in subcutaneous fiber, then one should subcutaneously direct dissected tendons of anterior tibial and long fibular muscles onto plantar rear area to suture them so to leave free the tendinous end of posterior tibial muscle which should be intraosseously fixed to median wedge bone that keeps the process of foot repulsion during walking.

EFFECT: higher efficiency of therapy.

5 dwg, 1 ex

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