Method for talocrural arthrodesis at incorrectly fused fibular fractures and those of posterior tibial edges

FIELD: medicine, traumatology, orthopedics.

SUBSTANCE: one should perform incision along internal surface of talocrural joint, open internal ankle and distal tibial metaepiphysis, perform osteotomy of internal ankle, remove cartilages at articular surfaces of internal ankle and internal department of patient's talus, carry out fibular osteotomy being above incorrectly fused fracture, dissect distal fibular fragment outwards, perform osteotomy of incorrectly fused fracture of posterior tibial edge to be then repaired and osteosynthesized, remove cartilages from articular surfaces of fibula and tibia and talus, remove posterior-external subluxation of talus, conduct temporal transarticular fixation of talocrural joint with needles at correct position of talus, perform osteosynthesis of osseous fibular fragments after osteotomy fulfilled, fix external ankle with a screw to tibial and talus epiphysis, perform osteosynthesis of internal ankle, remove transarticularly introduced needles, fill talocrural fissure developed with osseous transplants developed out of anterior-external department of distal tibial metaepiphysis.

EFFECT: increased accuracy of reposition, improved conditions for fusion.

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The invention relates to medicine, namely to traumatology and orthopedics, and can be used for arthrodesis of the ankle joint.

A known technique for arthrodesis of the ankle joint, which essentially boils down to the destruction of degenerative cartilage with the talus and the tibia and the moving bone grafts from the tibia to the talus, using different approaches and fixation of the ankle joint (Boychev, Conforti, Chukanov. Operative Orthopaedics and traumatology, 1961, pages 721-724, Movshovich IA Operative Orthopaedics, 1983, pp. 285-288).

The prototype of an invention is patent No. 2185793 "Method of arthrodesis of the ankle joint", Bulletin No. 21 from 27.07.2002, proposed Dolgopolova CENTURIES, Satie A.S.

The authors suggest to perform an osteotomy of the fibula 2 cm above the joint space, cut the front of tibiofibular ligament of SYNDESMOS and ligaments in the apex of the external malleolus, turn the outer ankle outwards, then remove the cartilage from the articular surfaces of bones that form the ankle joint. Fill in the gap lamellar bone grafts and fix the outer ankle screw to the epiphysis of the tibia.

However, when the stage of operation of arthrodesis of the ankle joint by well-known methods when wrong with OSISA fractures of the fibula, combined with fracture of the posterior edge of the tibia, often persists rear-outer subluxation of the talus, just to otremontirovat malunion fibula after the osteotomy, particularly in deferred time. This is because surgeons underestimated, the fact that shifting medially of the inner ankle under pronating fractures, firstly, prevents the removal of the rear-outer subluxation of the foot.

Secondly, without osteotomy performed, then reposition and fixation incorrectly fused fracture posterior edge of the tibia is difficult for the elimination of back-outer subluxation of the talus and the subsequent execution of arthrodesis of the ankle joint in the correct position of the talus and fibula. This is because surgeons underestimated the fact that shifting outwards, backwards and upwards, the distal fragment of the fibula is connected through the posterior tibiofibular ligament with the back edge of the tibia. When unresolved offset rear edge of the tibia is difficult for the fixation of the fibula in the correct position, after previously held osteotomy, is sharply limited her mobility, and thus hampered the conduct of its repositioning in tibiofibular cutting of the tibia. R is Szechenyi posterior and anterior tibiofibular ligament increases the invasiveness of the surgery, affects trophic distal fragment of the fibula;

Thirdly, when improperly fused fractures of the posterior edge of the tibia more than 1/3 of the articular surface and large displacements it up backwards and outwards surgeons often perform a large resection of the articular surface of the distal metapelite tibia for exact adjustment to ankle bone, while watching the destruction and weakening of the supporting surfaces of the bones that form the ankle joint, there are great technical difficulties in filling height of the joint space of the ankle joint after removal of cartilage and subchondral layer of the talus and the tibia;

Fourthly, when the mobilization of external ankle by a known method for performing spinal fusion, additionally damaged calcaneal-fibular ligament, it can lead to instability of the ankle-heel joint.

This method is adopted for the prototype.

The aim of the invention is to provide a method of arthrodesis of the ankle joint when improperly fused fractures of the fibula and posterior edge of the tibia, which eliminates the back-outer subluxation of the talus, just to otremontirovat fragments incorrectly fused fracture of the fibula and posterior edge of the tibia.

The achievement of the put is authorized purpose carry out those the operation of fusion when improperly fused fractures of the fibula and posterior edge of the tibia is carried out in strict sequence, initially producing mobilization of bone structures without their recovery in an internal Department of the ankle joint, then perform the osteotomy of the fibula above incorrectly fused fracture, cut the front of tibiofibular ligament of SYNDESMOS, turn the distal fibula fragments outwards, making the osteotomy incorrectly fused fracture posterior edge of the tibia, then it just repairbot and spend osteosynthesis, remove the cartilage from the articular surfaces of the tibia and talus, remove rear outer subluxation of the talus and produce transarticular fixing spokes in the correct position, produce fixation of the fibula, the outer ankle is fixed by screw to the epiphysis of the tibia and talus, produce osteosynthesis of the inner ankle, remove transarticular held spokes, the gap of the ankle joint is filled with bone transplantation formed from the front end of the outer division of the distal metapelite tibia.

The essence of the invention lies in the fact that when correctly fused fractures malabarba the bone and the posterior edge of the tibia, when performing arthrodesis of the ankle joint used method for the mobilization of a fragment of the rear edge of the tibia through the region of the anterior tibiofibular ligament that helps to mobilize the distal fibula fragments and fragments of the posterior edge of the tibia associated with the rear tibiofibular ligament without damaging it, then just to repairbot fragments of the posterior edge of the tibia and spend it osteosynthesis in the correct position, osteosynthesis wrong accrete fibula fracture is carried out after the fixation of the posterior edge of the tibia, at the final stage of surgical intervention in the gap of the ankle joint after resection of the articular surfaces of bones that form the ankle joint, filled with graft formed from the front end of the outer Department distal metapelite tibia.

To understand the essence of the proposed method of arthrodesis of the ankle joint when improperly fused fractures of the fibula and posterior edge of the tibia, you must know the mechanism and the nature of this damage

For example, when nadenessnick fractures of the fibula, combined with fracture of the posterior edge of the tibia in the mechanism of formation of this type of damage is Denia have the value of the sequential movement of the foot: its abstraction, Mercia and plantar flexion (moving the rotation of the talus laterally of the longitudinal axis of the foot, then everse-rotation around the longitudinal axis of the leg, breaking into plantar flexion-rotation of the talus around megadigital axis). The rotation of the talus laterally of the longitudinal axis of the foot tension arises in the "rigid" an internal Department of the ankle joint, rupture of the deltoid ligament or tear fracture of the inner ankle. Having "freedom", shifting laterally of the talus, the rotation around the longitudinal axis of the shank carries out the pressure on the front edge of the outer ankle. The anterior tibiofibular ligament, resisting this movement, straining, and, not withstanding this resistance is broken. When plantar flexion of the foot, the talus retreats around megadigital axis, the block talus presses on the back part of the articular surface of the tibia backward, leads to broke off a significant slice of the rear edge and fracture of the fibula to the level of the upper border of attaching the rear tibiofibular ligament. Occurs pronation-eversion plantar perelomova in the ankle joint. The rear edge of the Shin bone (tibia) and shifting Karu and and posterior to the distal fragment of the fibula, linked rear tibiofibular ligament, creating the problem of instability damaged ankle in these areas.

The talus is losing support in the external-the posterior part of the ankle joint and is easily displaced in this direction. The extension of the fork of the ankle joint and subluxation of the foot outwards and backwards.

On figa presents the image of the ankle joints in a direct projection: rupture of the deltoid ligament, fracture of the fibula, posterior edge of the tibia.

On figb presents the image of the ankle joint in a straight projection of the inner ankle fracture, fibula fracture, posterior edge of the tibia.

On FIGU presents the image of the ankle joint in lateral projection of the fibula fracture in combination with fracture of the posterior edge of the tibia.

On Figg presents a horizontal slice of the tibia bone at the level of the distal tibiofibular of syndesmosis along the line a-a', fractured fibula in combination with fracture of the posterior edge of the tibia.

Thus, the rear and outer sections of the joint fork, as if the mechanism of injury, losing support, easily dislodged in the rear-outer direction.

The method of arthrodesis of the ankle joint when dannenbring as follows.

The first phase of the operation is a longitudinal section along the inner surface of the ankle joint reveal the inner ankle and the distal metapages of the tibia. When improperly fused the fracture of the inner ankle produce osteotomy. In cases of non-consolidation of internal fracture of the ankle or with long-standing gaps deltoid ligament produce destruction modified scar tissue in the area of the inner malleolus and the deltoid ligament. We do not cut off the inner ankle from the deltoid ligament, it breaks the power of the inner ankle, and can lead to avascular necrosis and nonunion. In the case of incorrectly fused fracture of the inner ankle internal ankle after osteotomy easily turn medially and open access to the ankle on the inner side (figb). Of access to the joint space between the inner ankle and the lateral surface of the talus remove the cartilage on the articular surfaces of the inner ankle and the internal division of the talus. Then inside put guiding seams as during continuing operation comes retraction of the skin and soft tissues, which can negatively affect the tissues during suturing of the wound.

The second phase of the operation - from the anterior-medial incision along the front edge of the fibular to the STI parallel to the superficial branch of the peroneal nerve reveal fibula with its level of improperly fused fracture or false joint to its top. Make osteotomy 0.5 cm above incorrectly fused fracture of the fibula, dissect the anterior tibiofibular ligament of SYNDESMOS, dissect the anterior talofibular ligament, turn the distal fibula fragments outwards. Calcaneal-fibular ligament us is not damaged, as this may lead to instability of the ankle-heel joint (figa). When the rotation mobilized distal fragment of the fibula laterally of the visually determine the crack of the ankle joint and the line of fracture of the posterior edge of the tibia, revealed the degree of offset of the fragment rear edge more bone (figa and 2B.). If necromania fracture posterior edge of the tibia through the plane of the fracture to produce the mobilization and removal of scar tissue between the fragments, at the wrong his Union and his significant shift upwards and outwards to produce the osteotomy line incorrectly fused fracture in the frontal plane. The rear edge of the tibia in the norm associated with the posterior tibiofibular ligament to the distal tomcom fibula. The mobilization of the posterior edge of the tibia produced together with the posterior tibiofibular ligament, without partial or complete dissection. Remove loose small bone fragments between the fragments is the tibia, do not damage the joint capsule, attached to a fragment of the rear edge.

The third stage of fragments rear edge of the tibia under visual control, reduce, just install it along the line of fracture and produce a temporary fixation of the two metal spokes, with Vicolo them over the skin of the lower third of the leg (figa). Perform radiological control of the reposition the rear edge of the tibia in lateral projection. For this purpose it is necessary to strictly projected x-ray beam along megadigital line at the level of the joint space.

After quality assessment reposition the rear edge of the tibia osteosynthesis is the rear edge of the tibial screw (rarely two) or kanalirovaniem screw (rarely two), introduced through the tibial metaphysis in the rear edge from front to back. After insertion of the screw (screws) spokes, temporarily fixing fragments rear edge of the tibia, is retrieved (figb).

The fourth step is to remove the cartilage from the articular surfaces of the tibia and talus, provide maximum contact of both ankles with side departments of the talus and distal metabilism of the tibia. Produce the elimination of external subluxation of the talus, thus shifting medially of the inner ankle when pronation what's fractures, after mobilization of internal and external departments damaged ankle joint does not prevent removal of the outer subluxation of the foot. After elimination of chronic subluxation of the foot outwards and backwards to produce a temporary transarticular fixation of bone fragments that form the ankle joint in the correct position, the two spokes.

The fifth stage - produce the osteosynthesis of bone fragments fibula after the osteotomy, in the correct position, only compressicauda plate. For the strength of fixation and improve contact of the bones that form the ankle joint with the operation of the arthrodesis, distal fragment of the fibula is fixed to the epiphysis of the tibia and talus two cancellous screws entered in block talus (figa), in the position of flexion of the ankle joint angle 110 deg. Internal ankle after the osteotomy is fixed to the distal metapelite tibia malleolar screw.

The sixth stage - remove transarticular conducted through joint spokes.

After resection of the distal tibiofibular of syndesmosis provide additional compression tibiofibular articulation cancellous screws inserted through the outer ankle in the distal metaphys the tibia parallel to "articulate the th" surface. The reduced diameter distal metapelite tibia, decreases the distance megadigital plug is damaged ankle. The gap of the ankle joint fill cancellous grafts formed from the front end of the outer division of the distal metapelite of the tibia. You can take grafts from crest Powszechny bones. The obtained graft drive in the gap of the ankle joint. When driving transplant occurs wedging effect, which creates an internal smokerise astrodatabank ends of the tibia and the talus bone (figa, 3b). Fill height of the joint space of the ankle joint, which is formed after removal of the cartilage and subchondral layer with the tibia and talus bones that form the ankle joint.

It is possible to carry out compression of the bones that form the ankle joint, between a bolt-tie, entered from the bottom up through the top of the fibula, block talus, it also creates ideal conditions for the formation of ankylosis of the ankle in the correct position.

On figa presents the image of the ankle joints in a direct projection of the fibula fracture in combination with fracture of the posterior edge of the tibia is the donkey operation of arthrodesis of the ankle joint, fixation of the fibula, the internal malleolus and the posterior edge of the tibia.

On figb presents the image of the ankle joint in lateral projection, after the operation of arthrodesis of the ankle joint, bone (distal fibula fragments not shown) of the rear edge of the tibia, removed articular surfaces of the tibia and the talus bone defect of the articular surface is filled with graft, figa and 3b, the area of insertion of the graft is shaded.

On Figg presents a horizontal slice of the tibia bone at the level of the distal tibiofibular of syndesmosis along the line a-a', fibula fracture, combined with fracture of the posterior edge of the tibia after the operation of arthrodesis of the ankle joint, held osteosynthesis rear edge of the tibia.

Toilet ran. The control of hemostasis. Layer-by-layer closure of wounds of abandonment drains. After removal of sutures limb immobilizer circular plaster cast "boot" to the upper third of the leg for a period of 3-4 months, prior to the formation of ankylosis of the ankle joint.

The proposed fusion of the ankle joint allows the open reposition correctly fused fracture of the fibula and posterior edge of the tibial coast is, to resolve chronic subluxation of the talus backwards and outwards, to save power, the fragment of the rear edge of the tibia, outer ankle, to improve the conditions of fusion of the bones that form the ankle joint.

The proposed method of arthrodesis for post-traumatic deforming arthrosis of the ankle joint after intra-articular dislocations fractures is intended for use in clinics, orthopedic-traumatological.

The method of arthrodesis of the ankle joint when improperly fused fractures of the fibula and posterior edge of the tibia, including osteotomy of the fibula, the dissection of the anterior tibiofibular ligament of SYNDESMOS, turn the distal fragment of the fibula laterally of the incision on the inner surface of the ankle joint, removing cartilage from the articular surfaces of the tibia and talus, filling gaps bone grafts, fixation of the fibula, characterized in that first make a cut on the inner surface of the ankle joint, exposing the inner ankle and the distal metaphys tibia, produce osteotomy of the inner ankle, remove the cartilage on the articular surfaces of the inner ankle and the internal division of the talus then make the osteotomy small the bone above incorrectly fused fracture, dissect the anterior tibiofibular ligament of SYNDESMOS, turn the distal fibula fragments outwards, making the osteotomy incorrectly fused fracture posterior edge of the tibia, then it repairbot and produce osteosynthesis, remove the cartilage from the articular surfaces of the tibia and talus, eliminate the posterolateral subluxation of the talus, produce temporary transarticular fixing the spokes of the foot and ankle in the correct position of the talus, produce the osteosynthesis of bone fragments fibula after the osteotomy, the outer ankle is fixed by screw to the epiphysis of the tibia and talus, produce osteosynthesis of the inner ankle, remove transarticular held spokes, the gap of the ankle joint is filled with bone grafts, formed from peregrinating Department distal metapelite tibia.