Method for treating displaced fractures of both columns of acetabulum

Abstract

FIELD: traumatology; orthopedics.SUBSTANCE: used in the treatment of displaced fractures of both columns of the acetabulum (AC). After performing repositioning and metal osteosynthesis of the anterior column of the acetabulum, X-ray control is performed. A proximal support consisting of two halves is formed on bone rods inserted into the iliac bones. On the hip, on the bone rods, on the side of the acetabulum fracture, in a position of its internal rotation by 10° , a distal support along the outer surface is formed with the possibility of movement, distraction and lateralization. The proximal and distal supports are connected by rods, with the help of which distraction along the axis of the femur is performed by 2 cm and its lateralization by rods by 1.5 cm, the apparatus is stabilized, and X-ray control is performed.EFFECT: method ensures anatomically correct restoration of the acetabulum and its reliable stabilization, allowing the patient to be activated at an early stage due to the formation of a proximal support from two halves on bone rods inserted into the iliac bones, creating the ability to produce and maintain internal rotation of the hip, distraction and lateralization of the hip along its axis due to internal rotation of the hip by 10°, creating tension in the short external rotators of the hip.1 cl, 4 dwg, 1 ex

Description

[0001] The invention relates to medicine, namely, to traumatology and orthopedics, and can be used in the treatment of displaced fractures of both columns of the acetabulum.

[0002] It is known that currently open reduction and internal fixation (ORIF) remains the standard method for treating pelvic and acetabular (AP) fractures [1, 2, 3]. However, the known approaches have drawbacks: blood loss during ORIF of the AP columns depends on the trauma and the length of the approaches used, and reaches 600 to 2000 ml or more [4, 5, 6]. These technologies, when planning surgical intervention, imply taking into account the anatomical and functional features of the pelvic ring. They usually cause the polyfocal nature of fractures with damage to the anterior column. This is more pronounced in two-column fractures. The reason for this is the close location of the fusion zone of the arcuate line of the ilium with the pubic crest (stress concentrator), which is directly involved in the formation of the anterior column. Moreover, the axes of the compressive forces of the symphysis and sacroiliac joints (SIJ) pass precisely through this area.The mechanical axes of pelvic loads are directly related to the arcuate lines of the iliac bones. Accordingly, reduction and stabilization of anterior column fractures begins with the proximal sections of the damaged pelvic bone. Reposition and osteosynthesis for two-column pelvic fractures also begin at this stage. With adequate reduction of the anterior column, its displacement in the posterior sections remains minimal. Only with this sequence are the conditions for restoring the mechanical axes of pelvic loads and anatomical repositioning of the posterior sections of the pelvic bone created [7].

[0003] Minimally invasive and minimally traumatic percutaneous osteosynthesis with cannulated screws is also known. However, it has not only advantages but also some limitations [8]: indications for percutaneous pelvic fixation include fractures with minimal displacement of the pelvic ring and pelvic vertebrae, fractures whose displacement can be reduced by closed reduction, as well as complex fractures requiring a combination of closed and open reduction techniques.

[0004] The closest in its technical solution to the claimed one is a method for treating displaced transacetabular pelvic fractures [9]. The operation according to this method includes the following: a bar with a bone rod inserted extraperitoneally into the pubosciatic column is mounted on sliding spacers connecting the halves of the proximal support of the apparatus, placed on the iliac bones, with the possibility of movement and fixation, while the rod is movably connected to the bar.

[0005] However, such a layout of the rod apparatus does not provide the possibility of repositioning all displacements of the explosive columns.

[0006] The aim of the invention is to reduce the trauma of surgical intervention while improving treatment results.

[0007] The essence of the proposed invention is expressed by a set of essential features sufficient to achieve the desired technical result, and consists in ensuring anatomically correct restoration of the cervical vertebrae and its reliable stabilization, allowing the patient to be activated at an early stage.

[0008] The method for treating displaced fractures of both acetabular columns involves the application of an external fixation device and repositioning of the fragments using rods. After repositioning and metal osteosynthesis of the anterior acetabular column, X-ray control is performed. A proximal support consisting of two halves is formed on bone rods inserted into the iliac bones. A distal support is formed on the femur, on the bone rods on the side of the acetabular fracture, with its internal rotation at 10°, along the outer surface, allowing for displacement, distraction, and lateralization. The proximal and distal supports are connected by rods, which provide 2 cm of distraction along the femoral axis and 1.5 cm of lateralization using rods. The device is stabilized, and X-ray control is performed.

[0009] Reposition and metal osteosynthesis of the anterior column of the acetabulum is justified by the anatomical and functional features of the pelvic ring: conditions are created for the restoration of the mechanical axes of the pelvic loads, which, accordingly, ensures the reposition and anatomically correct restoration of the acetabulum, while only the residual displacement of the fragments of the posterior column is preserved.

[0010] Formation of a proximal support from two halves on bone rods inserted into the iliac bones and its connection with rods with the formed distal support on the femur, on bone rods, on the side of the acetabulum fracture, along the outer surface, provides the ability to produce and maintain internal rotation of the hip, distraction and lateralization of the hip along its axis.

[0011] Internal rotation of the hip by 10° ensures reliable splinting of the fracture due to the tension of the short external rotators of the hip.

[0012] Distraction along the femur axis by 2 cm under conditions of internal rotation, and its lateralization by 1.5 cm, ensure the final reposition of the residual displacement of the posterior column fragments due to the tension of the ligament-capsular apparatus of the hip joint.

[0013] The method is explained by the following illustrations, where:

[0014] In Fig. 1. - external fixation device;

[0015] Fig.2 - Fig.4 explain a clinical example, where:

[0016] Fig. 2-a, Fig. 2-b shows a 3-D reconstruction of the CT scan of the pelvis of patient X. upon admission to the emergency room;

[0017] In Fig. 3-a, Fig. 3-b, Fig. 3-c - 3-D reconstruction of CT scan of the pelvis of patient X. after surgery;

[0018] Fig. 4-a, Fig. 4-b, Fig. 4-c - 3-D reconstruction of CT scan of the pelvis of patient X. after dismantling the external fixation apparatus.

[0019] The method is carried out as follows.

[0020] The patient is placed on the orthopedic table. The ilioinguinal approach of Judet-Letournel is performed, followed by reduction and metal osteosynthesis of the anterior column of the acetabulum. X-ray control is performed. A proximal support 1, consisting of two halves (Fig. 1), is formed on the ilium. A distal support 2 is formed on the femur, on the side of the pelvic fracture, in a position of its internal rotation by 10° along the outer surface. Proximal 1 and distal 2 supports are connected with rods 3. Distraction along the femur axis is performed with rods 3 by 2 cm, and its lateralization with rods 4 by 1.5 cm. Stabilization of the apparatus is performed. X-ray control is performed.

[0021] Clinical example.

[0022] Patient H., 43, was hospitalized from the scene of a traffic accident with a diagnosis of closed comminuted polyfocal fracture of the left pelvic bone: comminuted fracture of the body and wing of the ilium with displacement, displaced fracture of both columns of the acetabulum (Fig. 2-a, Fig. 2-b). Skeletal traction was applied. Preparation for surgical treatment.

[0023] Surgery after 12 hours: open reduction and metal osteosynthesis of the ilium and anterior acetabular column. External fixation device.

[0024] In the supine position, after preparing the surgical field, the ilium and anterior acetabular column were repositioned and reconstructed with reconstructive plates through the Judet-Letournel ilioinguinal approach. X-ray control was performed. A tubular drain was placed in the wound, and the wound was sutured.

[0025] A proximal support 1 consisting of two halves is formed on the rods installed in the iliac bones (three in each) (Fig. 1). On the left hip, in a position of its internal rotation of 10°, a distal support 2 is formed along the outer surface. Proximal 1 and distal 2 supports are connected by rods 3. Distraction along the femur axis by rods 3 by 2 cm is performed, and its lateralization by rods 4 by 1.5 cm. Stabilization of the apparatus. Aseptic dressings. X-ray control. The next day, the patient was put on crutches, taught to walk, and an CT scan of the pelvis was performed (Fig. 3-a, Fig. 3-b, Fig. 3-c).

[0026] At 10 weeks, the device was dismantled (Fig. 4-a, Fig. 4-b, Fig. 4-c), and the patient was sent to a rehabilitation center.

[0027] Sources of information:

[0028] 1. Judet R., Judet J., Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report / / J. Bone Joint Surg. Am. 1964. Vol. 46. ​​P. 1615-1646.

[0029] 2. Tornetta P. 3rd. Non-operative management of acetabular fractures. The use of dynamic stress views / / J. Bone Joint Surg. Br. 1999. Vol. 81, No. 1. P. 67-70. DOI: 10.1302 / 0301-620x.81b1.8805.

[0030] 3. Comparison of open reduction and internal fixation and primary total hip replacement for osteoporotic acetabular fractures: a retrospective clinical study / SP Boelch, MC Jordan, RH Meffert, H. Jansen / / Int. Orthop. 2017. Vol. 41, No. 9.P. 1831-1837. doi:10.1007 / s00264-016-3260-x.

[0031] 4. Possibilities of surgical treatment of acetabular fractures using minimally invasive technologies / A.F. Lazarev, E.I. Malt, A.S. Roskidaylo, A.A. Lazarev, M.G. Kakabadze, Ya.G. Gudushauri, I. Dan / / Bulletin of Traumatology and Orthopedics named after. N.N. Priorova. 2009. No. 2. P. 3-9.

[0032] 5. Effects of the incısıon preference ın acetabular surgery on the postoperative functıonal outcomes / M. Erem, C. Copuroglu, E. Copuroglu, M. Ciftdemir, M. Ozcan, K. Saridogan / / Niger. J. Clin. Pract. 2019. Vol. 22, No. 6. P. 862-868. DOI: 10.4103 / njcp.njcp_455_18.

[0033] 6. Management of acetabular fractures in the geriatric patient / M. Hanschen, S. Pesch, S. Huber-Wagner, P. Biberthaler / / SICOT J. 2017. Vol. 3.P. 37.doi:10.1051 / sicotj / 2017026

[0034] 7. Khabibyanov R.Ya. Treatment of unstable injuries of the pelvic ring and fractures of the acetabulum: author's abstract. dis. doctor of medical sciences. - Kazan, 2016. - 39 p.

[0035] 8. Operative versus non-operative treatment of displaced acetabular fractures in elderly patients / M. Boudissa, F. Francony, S. Drevet, G. Kerschbaumer, S. Ruatti, M. Milaire, P. Merloz, J. Tonetti / / Aging Clin. Exp. Res. 2019. DOI: 10.1007 / s40520-019-01231-5.

[0036] 9. Russian Federation Patent No. 2195223 A61B 17 / 56, A61B 17 / 60, BI No. 36, 2002.

Claims

A method for treating displaced fractures of both columns of the acetabulum, including the application of an external fixation device and repositioning of fragments using rods, characterized in that after performing repositioning and metal osteosynthesis of the anterior column of the acetabulum, X-ray control is performed, a proximal support consisting of two halves is formed on bone rods inserted into the iliac bones, a distal support is formed on the femur on bone rods on the side of the acetabulum fracture, in a position of its internal rotation by 10°, along the outer surface with the possibility of displacement, distraction and lateralization, the proximal and distal supports are connected by rods, with the help of which distraction along the femur axis is performed by 2 cm, and its lateralization by rods inserted into the femur by 1.5 cm, the apparatus is stabilized, X-ray control is performed.

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