RU-2861494-C1 - METHOD FOR TREATING INTRAOPERATIVE FEMORAL FRACTURES IN PATIENTS WITH OSTEOMYELITIS OF BONES FORMING HIP JOINT

RU2861494C1RU 2861494 C1RU2861494 C1RU 2861494C1RU-2861494-C1

Abstract

FIELD: medicine; surgery. SUBSTANCE: invention can be used in traumatology and orthopaedics for treating intraoperative femoral fractures in patients with osteomyelitis of the bones forming the hip joint. The method includes fracture reduction, forming a spacer with a cement antibacterial mantle and subsequent blocking thereof in the distal part of the femoral medullary canal. The spacer is assembled from a wedge-shaped femoral component of the endoprosthesis and an intramedullary rod. The ratio of the components is determined such that the distal part of the wedge-shaped femoral component of the endoprosthesis is immersed in the proximal part of the rod channel so that the length of the femoral component protruding from the rod channel is 70% of its total length. The depth of the femoral medullary canal from the level of the femoral cut to the distal metaphyseal region is determined, and the length of the rod is obtained by subtracting the length of the protruding portion of the wedge-shaped femoral component stem from the obtained value of the depth of the medullary canal. The diameter of the rod is determined after reaming the medullary canal with flexible reamers in the narrowest part of the femur. To manufacture the spacer, the distal end of the femoral component is inserted into the proximal part of the channel of the femoral intramedullary rod and wedged into the rod. A silicone tube is selected with a length equal to the length of the assembled spacer, wherein the diameter of the intramedullary rod is 2 mm smaller than the inner diameter of the silicone tube. The distal holes for the locking screws of the rod are filled with surgical wax. Then, the silicone tube is filled with bone cement with antibiotic, into which the assembled spacer is immersed. After the bone cement polymerises, the silicone tube is cut and removed, and the distal holes of the intramedullary rod are freed from bone cement and wax. An additional portion of bone cement with antibiotic is applied to the surface of the femoral component protruding above the rod. The spacer is inserted into the femoral medullary canal to the depth of insertion of the femoral component until the additional portion of bone cement on the proximal part of the spacer polymerises. Under EOT control, distal locking of the structure is performed with four screws. An endoprosthesis head is placed on the cone of the femoral component and reduced into the acetabular component. EFFECT: restoration of joint function, increasing the effectiveness of the debridement stage of revision arthroplasty, which allows reducing the risk of infection recurrence by creating conditions for consolidation and controlling the infectious process. 1 cl, 14 dwg, 2 ex

Inventors

Astakhov Denis Igorevich
Artiukh Vasilii Alekseevich
Afanasev Aleksandr Vitalevich
Toropov Sergei Sergeevich
Antipov Aleksandr Pavlovich

Dates

Publication Date: 20260505
Application Date: 20250930

Claims (1)

A method for treating an intraoperative femur fracture in patients with osteomyelitis of the bones that form the hip joint, including repositioning the fracture, forming a spacer with a cement antibacterial mantle and subsequently blocking it in the distal part of the medullary canal of the femur, characterized in that the spacer is assembled from a wedge-shaped femoral component of the endoprosthesis and an intramedullary rod, while the ratio of the components is determined in such a way that the distal part of the wedge-shaped femoral component of the endoprosthesis is immersed in the proximal part of the rod channel in such a way that the length of the part of the femoral component protruding from the rod channel is 70% of its total length, then the depth of the medullary canal of the femur is determined from the level of the femoral cut to the distal metaphyseal region and the length of the protruding part of the wedge-shaped leg is subtracted from the obtained value of the depth of the medullary canal femoral component, obtaining the value of the rod length, and the diameter of the rod is determined after rimming the medullary canal with flexible reamers in the narrowest part of the femur; to manufacture the spacer, the distal end of the femoral component is inserted into the proximal part of the canal of the femoral intramedullary rod and wedged in the rod; a silicone tube of a length equal to the length of the assembled spacer is selected, while the diameter of the intramedullary rod should be 2 mm less than the internal diameter of the silicone tube, then the distal holes for the locking screws of the rod are filled with surgical wax, then the silicone tube is filled with bone cement with an antibiotic, into which the assembled spacer is immersed; After the bone cement has polymerized, the silicone tube is dissected and removed, and the distal openings of the intramedullary rod are cleared of bone cement and wax. An additional portion of bone cement with an antibiotic is then applied to the surface of the part of the femoral component of the endoprosthesis protruding above the rod. Next, the spacer is inserted into the medullary canal of the femur to the depth of the femoral component seating until the additional portion of bone cement on the proximal part of the spacer has polymerized. After this, under the control of an image intensifier, the distal locking of the structure is performed with four screws, the head of the endoprosthesis is installed on the cone of the femoral component and is adjusted into the acetabular component.

Description

The invention relates to medicine, namely to surgery, and can be used in traumatology and orthopedics for the treatment of iatrogenic fractures of the femoral diaphysis that occur during radical surgical treatment (RST) for osteomyelitis (OM) of the bones that form the hip joint, including periprosthetic infection (PPI) of the hip joint (HJ) or in patients with infectious arthritis. The development of periprosthetic fractures (PPF) during surgical treatment of PPI is rightly considered the "worst-case scenario" for complications of revision hip arthroplasty [1]. According to published data, the incidence of intraoperative periprosthetic fractures (PPF) ranges from 0.1 to 27.8% (0.3-18% in primary and 0.3-17.6% in revision arthroplasty) [2, 3]. Data on the proportion of intraoperative PPF in patients with PPI of the hip are limited. In the reviewed publications, the number of cases of PPF of the femur during hip and knee arthroplasty does not exceed ten [4]. Surgical methods for fixing the femoral PPP include the use of oncologic megaprostheses, osteosynthesis of the femur on a long revision stem, the use of various fixation systems with plates, intramedullary rods, wire sutures, or the use of a combination of all of the above. K. Döring et al. (2021) believe that replacing a damaged femur with a megaprosthesis is technically feasible, but the service life of such implants is short. Approximately 64% of endoprostheses continue to function one year after surgery, 43% after five years, and 38% after ten years [5]. M. Tibbo et al. (2021) reported high results using open reduction and revision plate fixation of femoral PJI. Satisfactory outcomes were achieved in 81% of cases. However, the study was conducted shortly after surgery (up to 2 years), and there were no patients with PJI in the observation cohort [6]. In addition, R. Richard et al. (2020) compared the treatment outcomes of patients with PPI using a fixation plate and an intramedullary nail. The authors found no difference in the rate of unplanned revision surgeries (17.6 vs. 23.1%, p>0.99), infectious complications, or pseudoarthrosis between the comparison groups. At the same time, the use of an intramedullary nail reduced the surgical time (89 vs. 157 min, p<0.01) and blood loss (137 vs. 291 ml, p=0.03), while the patients' body weight was higher. However, as in the previous study, the treatment outcomes of patients with PPI of the hip were not studied [7]. The most accessible and, likely for this reason, widely used method of fixing the PPP is wire sutures. However, D. Karczewski et al. (2022) demonstrated that infectious complications following PPP fusion with cerclages were caused by pathogens with high antibiotic resistance, and the development of PJI was recorded at an earlier stage. Based on their own data, the authors recommended considering wire sutures as a potential source of reinfection during two-stage revision arthroplasty [8]. An analogue of the technique we propose is retrograde osteosynthesis of periprosthetic fractures with an intramedullary nail (RU patent #81637, RU patent #112024, RU patent #119600, RU patent #2545443) [9]. A. Chelnokov et al. (2012) developed a closed intramedullary revision osteosynthesis (ZIRO) system that ensures fracture stabilization, reliably fixes the structure, and creates conditions for the reintegration of the endoprosthesis stem. Despite significant positive experience, to date, the use of the ZIRO system has only been described in patients with periprosthetic fractures that occurred after surgery. At the same time, to use ZIRO for iatrogenic PJI of the femur, surgeons must have a specialized set of instruments and CITO implants at their disposal. One of the disadvantages of the ZIRO nail is its large diameter, which requires a large socket, leading to significant femoral condyle defects during reaming. Furthermore, the potential of ZIRO for treating patients with PJI remains unknown, and retrograde nail insertion carries a risk of knee joint contamination. And, of course, the main limitation of this technique is the need for a stable knee replacement. Another analogue of the technique we developed is a method for osteosynthesis of the pelvic arthroplasty (PAA) using a telescopic hip endoprosthesis (RU Patent No. 2715439) [10]. The idea behind fixing the PAA is to construct a hollow femoral component of the endoprosthesis, which houses two intramedullary pins made of a ferromagnetic material. The authors propose advancing the pins to the required depth within the medullary canal using a magnet and locking them distally with screws. The obvious disadvantages of this method include the complexity of the design, the high cost of the endoprosthesis, and potential problems associated with stocking the operating room with a full range of implant sizes. This last requirement stems from the fact that iatrogenic PAA develop unpredictably during revision arthroplasty, and their bone destruction patterns are var