RU2745232C1 - Osteotomy method of olecranon - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, and can be used for osteotomy of the olecranon. Osteotyped saw with the blade width of 9-15 mm performs an osteotomy, retreating 5-6 mm in proximal direction from the mark made by the awl above the center of the block-like notch. Osteotomy is performed on the posterior surface of the ulbar bone in the distal direction at angle of 45-50 degrees so that the depth of the saw blade immersion into the bone is uniform to depth of 5-7 mm. Thereafter, both sides of the ulnar bone are osteotomy, both lines of which converge to form a Y-shape with a previously performed osteotomy line.EFFECT: method provides higher effectiveness and reduced length of treatment of patients suffering from overconditional intraarticular fractures of humerus, requiring open osteosynthesis, by increasing congruence of bone fragments formed as a result of osteotomy.1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to methods of osteotomy used in traumatology and orthopedics.

In the treatment of intra-articular fractures of the distal humerus, complete anatomical reduction of bone fragments with restoration of the congruence of the articular components of the elbow joint is required. Therefore, unlike diaphyseal fractures of the humerus, intra-articular fractures with displacement of bone fragments, as a rule, are treated by open reduction and internal fixation, and minimally invasive osteosynthesis is used only in exceptional cases. The aim of the operation is the earliest possible anatomical restoration of the joint and stable fixation of bone fragments to enable active movements in it. The need for early development of movements in the elbow joint is due to the fact that this joint is most vulnerable to the development of postimmobilization contractures and ankylosis. For osteosynthesis of intra-articular transcondylar fractures of the humerus, two angularly stable reconstructive plates are usually used. The most convenient and functionally advantageous surgical approach for this is the posterior approach with cutting off the olecranon. After reconstruction and osteosynthesis of an intra-articular fracture of the humerus, the olecranon process is also restored.

Analogs

The operation is performed as follows. The position of the patient on the operating table is on the side or abdomen with the upper limb retracted at a right angle, placed on an X-ray support. The fracture is exposed with a posterior direct surgical approach from the upper third of the ulna to the border of the middle and lower third of the shoulder, bending around the olecranon from the radial side. For better revision and reconstruction of the distal part of the humerus with restoration of the congruence of the elbow joint, provisional osteotomy of the olecranon is performed.

Osteotomy of the ulna is performed over the block-shaped notch with a narrow straight chisel or saw - circular or oscillatory. Osteotomy with a chisel or circular saw, as a rule, is linear (transverse), and with an oscillary saw, in addition, it can be curly.

Criticism of analogues

Osteotomy of the olecranon with a chisel or circular saw is characterized by significant disadvantages associated with a decrease in their effectiveness, delay in the time of bone fragments fusion and the risk of complications from the osteotomy zone. These include the following:

- the problem of achieving precision accuracy of osteotomy with a decrease in its quality;

- the risk of the osteotomy line going beyond the intended and splitting off of bone fragments or crumbs from the osteotomy plane with the formation of bone defects on the osteotomy line, which is due to rigidity, hardness and anisotropy (that is, the difference in properties in different directions, even in homogeneous materials, due to the fact that the crystals of which they are composed have unequal properties in different directions, for example, for copper, the strength of crystals in different directions is more than 3 times different) bones at the site of osteotomy;

- a small length of the osteotomy surface and the risk of incomplete contact between bone fragments along the entire length of the osteotomy surfaces with an increase in the terms of further consolidation between bone fragments and, consequently, the likelihood of postimmobilization contracture of the elbow joint.

Prototype

As a prototype method, a V-shaped or angular osteotomy of the ulna was chosen (Traumatology and Orthopedics: A Guide for Physicians / Edited by N.V. Kornilov: in 4 volumes. - St. Petersburg: Hippokrat, 2004 - T. 2: Injuries and diseases of the shoulder girdle and upper limb / Edited by N.V. Kornilov and E.G. Gryaznukhin. - SPb .: Hippocrates, 2005 - 896 p. - S. 167-213), which consists in the following (Fig. 1, a , b, c, d, e). Using an oscillating saw, 4/5 of the bone diameter is cut on both lateral sides of the ulna at the level of its block-like notch, and the remaining part is split off with a chisel. After that, the dissected olecranon with the triceps tendon is retracted proximally (Fig. 1, a), and the osteotomy configuration is V-shaped (Fig. 1, b) with osteotomized planes converging at right angles into a vertical line (Fig. 1 ,at). After the proximal abduction of the severed olecranon process, the humerus is reconstructed. As a rule, osteosynthesis of an intra-articular transcondylar fracture is carried out with two plates with angular stability: a modeled reconstructive plate is placed on the postero-outer surface of the humerus, and a 1/3 tubular plate with the introduction of 3.5 mm screws is placed on the ulnar crest of the humerus. At the same time, both plates should not interfere with the immersion of the olecranon process into the fossa of the humerus. Then, reduction (Fig. 1, d) and osteosynthesis of the olecranon are performed with a cancellous screw and a cerclage wire or two parallel needles and a cerclage wire according to Weber (Fig. 1, e).

Criticism of the prototype

Angled or V-shaped osteotomy of the ulna has the following disadvantages:

- two converging planes of contact between the bone fragments provide rotational stability, but do not interfere with the sliding forces of the olecranon along the V-shaped line of the ulna osteotomy, which does not exclude the secondary displacement of the olecranon during osteosynthesis and does not contribute to optimal conditions for the formation of callus between bone fragments;

- the lack of optimal conditions for the formation of callus can cause a delay in the formation of bone adhesion between bone fragments and prevent the early activation of the injured limb with the prevention of contractures and muscle wasting.

The purpose of the invention is to improve the effectiveness of treatment of patients with intra-articular fractures of the distal humerus, who need open reduction and osteosynthesis with adequate access, namely with osteotomy, and then osteosynthesis of the olecranon.

The essence of the invention

The proposed method of osteotomy of the olecranon (Fig. 2, a, b), which consists in the intersection of the ulna at the level of its block-shaped notch, characterized in that the form of the osteotomy is Y-shaped. Osteotomy is performed as follows. Using an oscillating saw with a blade width 1.5 times inferior to the diameter of the ulna at the osteotomy level and equal to 9-15 mm, osteotomy is performed, 5-6 mm retreating proximally from the mark made with an awl above the center of the block-shaped notch on the posterior surface of the ulna to the distal side at an angle of 45-50 degrees so that the depth of immersion of the saw blade into the bone is uniform to a depth of 5-7 mm (Fig. 3, a), for which the blade of the oscillator saw is driven in both directions along the entire osteotomy line, then the blade is advanced deeply bone only in its middle part to a depth of 1/3 of the diameter of the bone (Fig. 3, b), while the end of the osteotomy in depth corresponds to the perpendicular from the mark made with an awl to the edge of the blade of the sides of the ulna at the same angle, guided by the same mark made with an awl on the surface of the ulna, perform an osteotomy, both lines of which, V-shaped converging with each other m, form a Y-shaped osteotomy (Fig. 3, c), while a narrow bone bridge often remains in the center of the Y-shaped osteotomy, which is broken down by introducing a narrow straight chisel into one of the three osteotomy lines or by a combination of traction and rotation of the olecranon, and if this bridge is broken on the surface of a smaller fragment of the ulna with a pointed triangular end, a thin thorn may remain, which corresponds to a fossa on another bone fragment, which further contributes to the congruence of bone fragments during their reduction and osteosynthesis. After performing osteosynthesis of a transcondylar intra-articular fracture of the humerus, bone fragments of the ulna are repositioned (Fig. 4, a) and osteosynthesis is performed with a cancellous screw or two parallel wires and a cerclage wire according to Weber (Fig. 4, b).

Example of application of the invention

As an example of the application of the proposed method of olecranon osteotomy, we present the following observation.

Patient Α., Born in 1997 (22 years old), was admitted to the Republican Center of Orthopedics and Traumatology (RCTO) in Makhachkala on March 26, 2020 with a diagnosis of Concomitant injury. Brain concussion. Closed fracture of the VI-VII ribs on the right. Closed transcondylar fracture of the right humerus with displacement of fragments.

On March 31, 2020, the operation was performed: Osteosynthesis of a transcondylar fracture of the right humerus with two reconstructive 3.5-mm plates with angular stability by transolecranon approach (with cutting off the olecranon process). In the position of the patient on the left side with the right upper limb retracted and laid on a support, a linear longitudinal skin incision was made along its posterior side from the level of the upper third of the ulna to the border of the middle and lower third of the shoulder, bending around the olecranon from the outside. For better revision and reconstruction of the distal part of the humerus with restoration of the congruence of the elbow joint, osteotomy of the olecranon was performed as follows. The posterior surface of the proximal ulna was exposed and skeletonized, and its block-like notch was determined with a puncture needle. At this level, a mark was made with an awl to guide the subsequent osteotomy. Above the center of the block-shaped notch of the ulna, 5 mm retreating proximal to the mark made with an awl, an osteotomy was performed obliquely inward and distally at an angle of 45 degrees with an oscillary saw with a 10 mm wide blade - so that the depth of immersion of the saw blade into the bone was uniform up to depth of 6-7 mm, for which the blade of an oscillating saw was driven in both directions along the entire osteotomy line. Then, the blade of a working oscillator saw was advanced deep into the bone only in its middle part to a depth corresponding to the perpendicular from the mark made with an awl on the surface of the ulna, which approximately corresponded to 11-12 mm, or 1/3 of the bone diameter. After that, sequentially on both lateral sides of the ulna at the same angle of 45 degrees, guided by the mark made with an awl on the surface of the ulna, an osteotomy was performed, both lines of which, V-shaped converging with each other, form together with the first line of osteotomy Y -shaped configuration of the olecranon osteotomy. At the same time, a narrow bone bridge remained in the center of this osteotomy, which was easily broken off by manual traction and turning the olecranon. When this bone bridge was broken, a thin thorn remained on the surface of a smaller fragment of the ulna with a pointed triangular end, which corresponded to a depression on another fragment of the ulna, which further contributed to the congruence of bone fragments during their reposition. The bone fragment together with the triceps tendon, mobilized by economical separation for 5 cm on both sides, was retracted proximally, which completely opened the fracture zone. Bone fragments of an intra-articular transcondylar fracture were revised, repositioned with provisional fixation with a Kirschner wire and synthesized with two reconstructive 3.5-mm plates with angular stability, one of which was laid along the postero-lateral surface of the humerus, and the second - at right angles to it and along the medial surface of the humerus with fixation with 3.5 mm screws with angular stability after preliminary drilling of the bony canals with a 2.7 mm drill. The provisional Kirschner wire was removed and the olecranon was repositioned. At the same time, the Y-shaped configuration of the osteotomy zone with a narrow spine in the center promoted congruence, reduction and stability of retention of bone fragments, which were fixed with two parallel wires and a Weber cerclage wire. Passive movements in the elbow joint were fully restored. On control radiographs, the position of bone fragments of the humerus and ulna is good. The wound is sutured in layers. Active movements in the elbow joint began on the second day after surgery. The postoperative period was uneventful, the wound healed primarily, the sutures were removed on the 8th day. The patient was discharged for outpatient treatment on 9.04.2020. The treatment result was assessed as good.

Features of the invention that differ from the prototype

The design features (distinguishing features from the prototype) of the olecranon osteotomy method are:

- Y-shaped osteotomy;

- at the level of the block-shaped notch of the ulna, make a mark with an awl as a guide;

- osteotomy is performed with an oscillating saw with a blade width that is approximately 2-3 times inferior to the diameter of the ulna at the level of the osteotomy, for example, the width of the bone at the level of the proposed osteotomy above the block-shaped notch is 28-30 mm, and the width of the saw blade is 10-12 mm;

- on the posterior surface of the ulna, osteotomy is performed 5-6 mm proximally from the mark made with an awl above the center of the block-shaped notch on the posterior surface of the ulna to the distal side at an angle of 45-50 degrees so that the depth of immersion of the saw blade into the bone is uniform up to depth of 5-7 mm, for which the blade of an oscillating saw is driven in both directions along the entire line of the osteotomy, then the blade is advanced deep into the bone only in its middle part to a depth of 1/3 of the bone diameter. In this case, the end of the osteotomy in depth corresponds to the perpendicular from the mark made with the awl to the edge of the oscillating saw blade;

- along the lateral surfaces of the ulna, osteotomy is performed sequentially at the same angle of 45-50 degrees, guided by the same mark made with an awl on the surface of the ulna, and both osteotomy lines V-shaped converging with each other, form with the previous line of osteotomy Y- shaped form of osteotomy;

- at the same time, a narrow bone bridge often remains in the center of the Y-shaped osteotomy, which is broken off by introducing a narrow straight chisel into one of the three osteotomy lines or by a combination of traction and rotation of the olecranon, and when this bridge is broken on the surface of a smaller fragment of the ulna with a pointed triangular end a thin spine may remain, which corresponds to a fossa on another bone fragment, which further contributes to the congruence of bone fragments during their reduction and osteosynthesis.

The technical result (advantages over the prototype) of the ulna osteotomy method:

- Y-shaped osteotomy determines a relatively large plane of contact between bone fragments and, therefore, more reliable and timely reparative regeneration, maturation and restructuring of callus;

- Y-shaped osteotomy and three planes of contact between bone fragments cause greater congruence of bone fragments, rotational stability and prevention of secondary displacement of the olecranon process during osteosynthesis and in the postoperative period;

- a bone thorn, often remaining in place of one of the bone fragments, due to the breaking of the bone bridge in the center of the three lines of the osteotomy, is completely congruent with the deepening on the second bone fragment, which, due to the greater scalloping of the bone fragments of the ulna, contributes to their better mutual adaptation and earlier adhesion between the osteotomized surfaces of bone fragments;

- a sufficient margin of rotational stability of the olecranon, due to a three-plane osteotomy and scallopedness of mutually adapted bone fragments, makes it possible to dispense with a smaller number of components of the metal structure, in particular when osteosynthesis of the olecranon with a screw, there is no need for rotational stability to also carry a Kirschner wire or use a cerclage wire;

- more reliable contact between bone fragments determines the possibility of earlier development of movements in the elbow joint, which, firstly, reduces the likelihood of postimmobilization contractures of the elbow joint, and secondly, early activation of the injured limb and muscle work improves blood circulation in it and prevents muscle wasting and thirdly, it activates the patient himself with a decrease in the likelihood of hypokinetic complications and an increase in his rehabilitation potential, which is especially important in elderly patients.

Thus, the proposed method of osteotomy of the ulna allows to increase the efficiency of treatment of patients with intra-articular fractures of the distal humerus, who need open reduction and osteosynthesis with adequate access, namely, with osteotomy, and then osteosynthesis of the olecranon.

Claims (1)

The method of osteotomy of the olecranon, which consists in the intersection of the ulna at the level of its block-shaped notch, characterized in that an osteotomy is performed with an oscillary saw with a blade width of 9-15 mm, retreating 5-6 mm proximally from the mark made with an awl above the center of the block-shaped notch on the posterior surface of the ulnar bone to the distal side at an angle of 45-50 degrees so that the depth of immersion of the saw blade into the bone is uniform to a depth of 5-7 mm, then the blade is advanced deep into the bone only in its middle part to a depth of 1/3 of the bone diameter, while the end osteotomy in depth corresponds to the perpendicular from the mark made with the awl to the edge of the oscillator saw blade, after which osteotomy is performed on both lateral sides of the ulna, both lines of which, converging, form a Y-shape with the previously made line of osteotomy.

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