Fractures in the knee joint
Thanks to the advent of new techniques and special materials, the results of surgical treatment of fractures have become better, even in patients with poor bone quality.
Timing of the operation. Most femoral condyle fractures are not treated immediately, with the exception of open fractures. Open fractures are characterized by the presence of communication between the fracture zone and the external environment. Such fractures require immediate surgical treatment.
In most cases, surgery is postponed for 1-3 days in order to choose the most optimal treatment plan and prepare the patient for surgery. Depending on your age and medical history, your surgeon may recommend further testing to ensure there are no significant health problems that need to be addressed before surgery.
External fixation. If there is significant damage to the soft tissue (skin and muscle) in the area of the fracture, or if your health makes you concerned about how you will cope with major surgery, your doctor may temporarily apply an external fixator. During this operation, metal needles or rods are inserted into the bones above and below the level of the fracture, which are fixed to an external fixation device. The latter is a frame that holds the bones in the correct position until you are ready for surgery.
An external fixator is used to temporarily stabilize the fracture before permanent fixation.
When you are ready for surgery, your surgeon will remove the external fixator and perform internal fixation of the fracture using some type of fixator.
Internal fixation. For fractures of the femoral condyles, the following fixation options are most often used:
- Intramedullary osteosynthesis. With this type of fixation, a special metal rod is inserted into the femoral medullary canal, which passes through the fracture area and fixes the fragments in the desired position.
- Bony osteosynthesis. During such an operation, the bone fragments are first returned to their normal position and fixed in this position on the outer surface of the bone with metal plates and screws.
With both fixation options, depending on the type of fracture and the fixator used, one large access or several small ones are performed.
Healed femoral fractures under conditions of extraosseous (left) and intramedullary (right) osteosynthesis.
In comminuted fractures, where there are many separate bone fragments, surgeons usually do not try to put them together like a puzzle. Instead, the surgeon uses a plate or rod that is secured above and below the fracture, leaving numerous bone fragments untouched at all. The goal of this operation is to restore the correct shape and length of the bone. The space between the individual fragments will eventually be filled with new bone tissue, called callus.
In comminuted fractures, the spaces between the individual fragments are filled with new bone tissue.
In cases where delayed fracture healing is expected, such as in elderly patients with poor bone quality, bone grafting may be performed to stimulate callus formation. The material for bone grafting can be taken from the patient himself (most often from the pelvis. It is also possible to use artificial bone substitutes for this purpose.
In the most severe cases of comminuted fractures and low quality bone tissue, when fixation of the fragments is impossible, they are removed and knee replacement is performed.
Fractures after knee replacement. Due to the aging population, the number of knee arthroplasty operations is increasing, and the number of fractures of the distal end of the femur in elderly patients who have previously undergone arthroplasty is also increasing.
Radiographs of a distal femoral fracture in a patient with a knee replacement.
For such fractures, intramedullary or external osteosynthesis is usually performed, as for conventional fractures of the distal femur. In rare cases, the original endoprosthesis is removed and replaced with a different version of the prosthesis. This operation is called revision of the endoprosthesis. It may be indicated when the components of the original prosthesis are destabilized or when it is impossible to fix the fracture using other methods.
Periprosthetic femoral fractures fixed with a plate, intramedullary rod, and also by revision knee replacement.
Surgical complications. You will be given antibiotics before surgery to prevent infection. You will also be prescribed anticoagulants (drugs that reduce blood clotting) to prevent blood clots from forming in the veins of the lower extremities.
Any operation is accompanied by some degree of severe blood loss. The amount of blood loss depends on the severity of the fracture and the nature of the operation. During the operation, the doctor will assess the amount of blood loss and, if necessary, give you a blood transfusion.
Introduction
Fractures of the humeral condyles in the structure of the annual incidence range, according to various estimates, from 5.7 to 34 per 100,000 population per year [5, 7]. The distribution is bimodal, with the first peak in incidence in young men under 19 years of age, usually as a result of high-energy injuries, and the second peak in older women with concomitant osteoporosis and disorders of bone tissue remodeling [6].
Fractures of the condyles of the humerus are among the most difficult in terms of surgical technique; in most cases, repositioning the fracture is difficult due to the comminuted nature of the fracture of the metaphyseal part and the articular surface, as well as concomitant osteoporosis [1, 3]. Currently, the standard surgical treatment for fractures of the humeral condyles is the method of external osteosynthesis with two plates with angular stability, but it has certain disadvantages. The method requires extensive posterior surgical access, either with cutting off the triceps muscle or with osteotomy of the olecranon, and during the operation, the isolation of bone fragments containing the articular surface, which is often the cause of suppuration and infectious complications. During the operation, it is often necessary to expose and isolate the radial nerve, which causes its neuritis in the postoperative period. The operation requires the presence of a coagulator, otherwise it is difficult to avoid massive intraoperative blood loss. In the postoperative period, heterotopic ossification often develops, which is the cause of pain and the formation of persistent contractures of the elbow joint. All of the above leads to mediocre and unsatisfactory treatment outcomes in almost 60% of cases [8-10]. Thus, the problem of treating fractures of the humeral condyles lies in the need to perform such osteosynthesis that would ensure not only stable and low-traumatic fixation of bone fragments, but also early functional activity of the damaged joint.
The purpose of this study is to improve the results of surgical treatment of intra-articular comminuted fractures of the humeral condyles using transosseous osteosynthesis with an external fixation device.
Material and methods
From 1998 to 2013, in the traumatology and orthopedics clinics of the Administration of the President of the Russian Federation, 55 patients with intra-articular comminuted fractures of the humeral condyles were operated on, and they underwent transosseous osteosynthesis using an external fixation device designed by A.I. Gorodnichenko.
Surgical treatment of fractures of the humeral condyles was carried out by the method of transosseous osteosynthesis using a pin-rod device, the main advantages of which were the stability of the achieved osteosynthesis for the entire period of treatment, elements of the device made of high-strength radiolucent carbon fiber, which made it possible to control the accuracy of closed reduction in all projections, unilateral location , compact dimensions and low weight of the entire structure, as well as “floating” rod holders that do not interfere with the elimination of all types of displacement of bone fragments [2]. Our experience has clearly shown the simplicity and safety of osteosynthesis with this device, the minimal trauma of the operation and the high stability of fixation of bone fragments even in patients with osteoporosis.
Indications for transosseous osteosynthesis with an external fixation device were open and closed comminuted intra-articular fractures of the humeral condyles, types 13-C1,2,3 according to the AO classification [4] (Fig. 1)
.
Figure 1. AO classification of intra-articular comminuted fractures of the humeral condyles (type 13-C1,2,3).
Among the injuries, open and closed fractures of types 13-C1,2 according to the AO classification predominated. In case of open injuries of this type, patients were operated on within the first 6 hours from the moment of admission. 13-C1 fractures occurred in 26 (47.2%) of our cases, 13-C2 fractures in 20 (36.4%) and 13-C3 fractures in 9 (16.4%) cases. All surgical interventions were performed on an orthopedic table under the control of an electron-optical converter. The method of anesthesia was either conduction anesthesia - brachial plexus block, or intravenous anesthesia. Reduction of the fracture, as a rule, was performed closed, and only in case of comminuted intra-articular fractures of type 13-C3, open reduction was performed in order to most accurately restore the congruence of the articular surfaces. The number of inserted rods depended on the nature of the fracture and the presence of concomitant osteoporosis. 1 or 2 rods and 1 or 2 wires with thrust pads were inserted into the area of the distal metaepiphysis of the humerus, which were attached from the outside in an external fixation apparatus. 1 or 2 cortical rods were inserted into the diaphysis of the humerus. All rods were inserted through skin incisions up to 5 mm long, which made it possible to reduce intraoperative blood loss to 10-30 ml and the duration of the operation to 30-45 minutes. Final reduction was achieved on the operating table using manual reduction tools, which was greatly facilitated by the fact that the main elements of the device were made of radiolucent carbon fiber.
No additional immobilization was required in the postoperative period. We attached particular importance to the rehabilitation treatment of patients after surgery. Passive movements in the operated joint were allowed from the first day after surgery, active movements - as the pain syndrome decreased - on the 3-4th day. In the early postoperative period, the Artromod device was used to passively develop movements in the operated limb. The stability of the fixation of the device, even in patients with osteoporosis, made it possible to develop movements in the operated joint in the coming days after surgery, which prevented the development of hypodynamic complications, contractures and deforming arthrosis. Patients were discharged from the hospital on days 8-12 after surgery.
Results and discussion
Consolidation of the fracture occurred in all observations. We did not notice any secondary displacement of fragments in the apparatus. The average fixation period was 78 days (range 65 to 98 days). The immediate results were assessed 2.5-3 months after surgery when the device was dismantled, long-term results were assessed 10-12 months after osteosynthesis based on clinical and radiological data.
A result was considered excellent when consolidation of the fracture occurred, the range of motion was restored to more than 80% of the original (110° or more), the patient’s subjective assessment of function was very good, and the patient returned to his previous work.
The result was regarded as good if consolidation of the fracture occurred, range of motion was restored to more than 65% of the original (from 90° to 109°), the patient’s subjective assessment of function was good, and the patient returned to some types of work.
The result was considered satisfactory when consolidation of the fracture occurred, range of motion was restored to more than 50% of the original (from 70° to 89°), the patient’s subjective assessment of function was satisfactory, and the patient was fully fit for light work.
The result was assessed as unsatisfactory when the range of motion was restored to less than 50% of the original (less than 70°), the patient’s subjective assessment of the function was unsatisfactory, and the patient was unable to work.
The devices were dismantled on an outpatient basis or patients were hospitalized in the hospital for one day. 1 year after osteosynthesis, out of 51 (92.7%) examined, 9 (17.6%) had excellent results, 24 (47.1%) had good results, and 18 (35.3%) had satisfactory results. There were no unsatisfactory results. Of the complications, 4 (7.3%) patients experienced inflammation of the soft tissues around the rods, which was relieved in the hospital and did not require dismantling the device.
To illustrate the results obtained, we present a clinical example.
Patient P.
, 25 years old, was admitted to the hospital with complaints of pain in the left elbow joint 2 hours after injury as a result of a fall on the street.
On examination, swelling of the left elbow joint, pain on palpation, and inability to move the joint due to pain were noted. After a clinical and radiological examination, a diagnosis was made: closed intra-articular comminuted transintercondylar fracture of the left humerus with displacement of fragments, type 13-C2 (Fig. 2)
.
Figure 2. Radiographs of patient P. with an intra-articular comminuted transcondylar fracture of the left humerus with displacement of fragments type 13-C2.
No vascular or neurological disorders were identified in the distal parts of the left upper limb. Upon admission, the fracture site was anesthetized and externally immobilized with a plaster cast.
The next day, an operation was performed under a novocaine brachial plexus block: closed reduction and transosseous osteosynthesis of the left humerus using a pin-and-rod external fixation device designed by A.I. Gorodnichenko. Through skin and soft tissue incisions up to 5 mm long along the outer surface of the left shoulder, 2 cortical rods were inserted into the diaphysis of the humerus, one cortical and one spongy rod, and 2 wires with a thrust platform into the condyles and epicondyles of the humerus. After fixing the proximal rods in the device under the control of an electron-optical converter, closed reduction was performed using removable handles, followed by stabilization of the distal rods and wires (Fig. 3)
.
Figure 3. Radiographs of patient P. after osteosynthesis of the left humerus with a pin-and-rod apparatus.
The skin around the rods is sutured with single sutures. Blood loss during the operation was 20 ml. The duration of the operation is 40 minutes. The postoperative course was without complications; regular dressings were performed with treatment of the skin around the rods and wires with antiseptic solutions and changing of aseptic dressings. The sutures around the rods were removed 8 days after surgery, the patient was discharged for outpatient treatment with recommendations for further rehabilitation treatment. Movements in the left elbow joint before discharge from the hospital are shown in Fig. 4
.
Figure 4. Radiographs of patient P. after osteosynthesis of the left humerus with a pin-and-rod apparatus.
After consolidation of the fracture, the device was dismantled 71 days later (Fig. 5)
.
Figure 5. Radiographs of patient P. after osteosynthesis of the left humerus with a pin-and-rod apparatus. Movements in the left elbow joint after dismantling the device from 0 to 128° (Fig. 6)
. Figure 6. Patient P.’s appearance after dismantling the device (range of motion in the left elbow joint from 0 to 128°).
Thus, our results of treatment of comminuted intra-articular fractures of the humeral condyles (type C according to the AO classification) using transosseous osteosynthesis with an external fixation device designed by A.I. Gorodnichenko testifies to its high effectiveness in creating stable osteosynthesis, which allows preserving the function of the damaged joint throughout the entire period of treatment, which, with regular physical therapy exercises, ensures the restoration of range of motion in the damaged joint and creates conditions for the restoration of patients’ ability to work. The use of low-traumatic transosseous osteosynthesis makes it possible to avoid significant blood loss during surgery, and the design features of the device reduce the duration of the operation.
The repeated use combined with the lower cost of the retainer compared to angularly stable plates guarantees significant economic benefits. Unilateral location and compact dimensions create conditions for improving the quality of life of patients in the postoperative period. Application of an external fixation device designed by A.I. Gorodnichenko makes it possible to improve the functional results of surgical treatment of comminuted intra-articular fractures of the humeral condyles and avoid unsatisfactory results. The use of the device reduces the duration of hospital treatment, rehabilitation and temporary disability of patients. The proposed method of treating fractures of the distal humerus can be recommended for wide practical use.
Osteoma of the condylar process of the mandible
Osteoma is a benign tumor of bone tissue, occurring in 2.7-5.9% of patients with benign tumors of the facial bones. Currently, it is suggested that the number of true osteomas is significantly smaller, since this diagnosis is often mistakenly made in cases of reactive hyperplasia, exostoses of the jaws, and some forms of fibrous dysplasia [3, 17].
Osteomas, as a rule, grow very slowly and painlessly, without making themselves felt for a long time. Their clinical picture is mild and depends on the location and size of the tumor. Developing in the area of the body of the lower jaw, osteomas lead to deformation of the corresponding area, aesthetic and functional disorders. Osteomas of the upper jaw with significant sizes cause exophthalmos, diplopia, lacrimation, impaired nasal breathing and neuralgic pain due to compression of the branches of the trigeminal nerve. When localized in the area of the frontal sinus and ethmoid labyrinth, the tumor is capable of deforming the walls of the sinuses, destroying them, growing into the orbit and cranial cavity [3, 15].
Damage to the condylar process of the mandible is quite rare and is characterized by specific symptoms. Osteomas of this localization present a certain difficulty for diagnosis and surgical treatment, remaining asymptomatic for a long time, but in later stages they can cause severe aesthetic and functional disorders [3, 9, 17].
Osteoma of the condylar process was first described in detail by Eckert (1899), pointing out displacement of the lower jaw, impaired mouth opening, as well as changes in facial contours on the side of the lesion of the condylar process of the mandible among its main clinical manifestations [1]. Subsequently, a few reports were presented in the literature, mainly about isolated observations of this disease [1, 11, 13, 14]. Deboise A. (1981), noting that osteoma is the most common benign neoplasm of the structures of the temporomandibular joint (TMJ), provides only 3 of his own observations [9]. The largest number of clinical observations of osteomas of the condylar process - 23 - belongs to H. Zhang (1997) [18]. The author, however, does not indicate whether in all cases the diagnosis of true osteoma was confirmed histologically.
Clinical observation
Patient K., 36 years old, medical history No. 4408 dated March 19, 2004, was admitted to the maxillofacial department No. 2 of City Clinical Hospital No. 12 in Kiev with complaints of facial deformation due to displacement of the lower jaw, malocclusion, difficulty chewing food, crunching in the left TMJ, moderate pain with increased load on the joint. For the first time, he noticed a facial deformity—a displacement of the chin to the right—in November 2002. Later, a clearer clinical picture emerged; the severity of the displacement and malocclusion slowly progressed until the moment of treatment. Objectively, the patient had pronounced facial asymmetry due to displacement of the lower jaw to the right (Fig. 1).
Rice. 1. The chin is shifted to the right side, a state of physiological rest.
In the pretragus area, the laterally displaced head of the left TMJ was clearly palpated. Mouth opening was up to 4.5 cm, with a crunch in the area of the left TMJ and a Z-shaped deviation of the lower jaw. Lateral movements of the jaw to the right were limited, the bite was oblique, and the midline shifted to the right by 1 cm (Fig. 2).
Rice. 2. In the pretragus area, the laterally displaced head of the left TMJ is clearly palpated.
A series of radiographs (orthopantomogram, radiograph of the mandible in direct projection and in the Haenisch position on the left, computed tomogram of the joint area with 3D reproduction) revealed a shadow of bone density with a size of 2x1.7 cm, associated with the left condylar process and located in the infratemporal fossa. The structures of the left TMJ were preserved, although somewhat deformed. When planning surgical intervention, a stereolithographic model of the patient’s skull was made (Fig. 3), on which the necessary measurements were made and the surgical approach was determined.
Rice. 3. Stereolithographic model of the skull, neoplasm of the left condylar process of the mandible.
On March 23, 2004, the patient underwent surgery: removal of a neoplasm of the condylar process of the lower jaw under endotracheal anesthesia with intubation through the nose. To do this, a preauricular and semicoronal approach was provided to the zygomatic arch, which was then resected and displaced downward on the fibers of the masseter muscle (Fig. 4).
Rice. 4. Surgical wound, coronal access, osteotomy of the zygomatic arch: 1 - zygomatic arch, 2 - osteotomy areas.
The fibers of the temporalis muscle were partially transected and detached, allowing access to the infratemporal fossa, where a bone formation was visualized anterior and medial to the head of the jaw (Fig. 5).
Rice. 5. The area of the infratemporal fossa, access to the tumor has been created.
The tumor is separated from the soft tissues and fixed using a special bone fixation made in the form of a corkscrew (Fig. 6).
Rice. 6. Macroscopic specimen of osteoma of the condylar process of the mandible.
The tumor was removed within the healthy bone. The zygomatic arch is placed in place and fixed with two wire bone sutures. The soft tissue flap was put in place, the wound was sutured in layers. The postoperative period proceeded without complications. Closing of the jaws in the correct position was noted the next day after surgery without any orthopedic measures (Fig. 7).
Rice. 7. State of physiological rest of the lower jaw on the first day after surgery. Closing of teeth in a physiological occlusion with restoration of the midline.
The radicality of tumor removal was confirmed by computed tomography data (Fig. 8).
Fig.8. Facial symmetry, state of physiological rest, 9 years after surgery.
Vertical movements of the lower jaw were fully restored on the 5th day. There was a slight paresis of the frontal and zygomatic branches of the facial nerve, the function of which was completely restored on the 7th day after surgery. Postoperative swelling of the temporal and zygomatic areas persisted for 8 days. On April 2, 2004, the patient was discharged in satisfactory condition with recommendations for rational prosthetics.
On January 16, 2013, patient K. underwent a repeated scheduled examination using clinical and instrumental research methods. The patient did not have any complaints from the TMJ. On bilateral palpation of the TMJ, no crunching or crepitus was observed, and there were no pain symptoms. Objectively: the contours of the face are symmetrical, the maximum opening of the mouth is 4 cm (Fig. 9, 10), the midline of the face is restored, the movements of the lower jaw are not limited, without signs of lateral deviation.
Rice. 9. Maximum mouth opening, 9 years after surgery. Rice. 10. Orthopantomogram, 9 years after surgery.
According to an orthopantomogram and computed tomography in 3D reconstruction mode, the structural elements of the left TMJ have clear anatomical contours and the structure of bone tissue is within normal limits. The relationship between the condylar process and the glenoid fossa ensured the functional stability of the TMJ and was considered acceptable (Fig. 11, 12).
Fig. 11. Computed tomography data. Rice. 12. 3D reconstruction of the skull, 9 years after surgery.
Discussion
Localization of osteoma in the TMJ region is a rare clinical situation. The paucity of clinical symptoms characteristic of osteomas determines the dominance in the clinical picture of nonspecific functional disorders of the TMJ, which makes it necessary to carry out differential diagnosis with other diseases of the joint - hyperplasia of the branch, deforming arthrosis, ankylosis, intra-articular disorders, habitual dislocation, etc. X-ray studies in standard settings are quite informative for making a correct diagnosis, but are clearly insufficient for choosing a method of surgical treatment. To clarify the localization of the tumor, taking into account the changed anatomical relationships, its relationship with the elements of the joint and the nature of structural changes in the latter, it is necessary to conduct computed tomography with 3D reconstruction. A thorough examination allows you to decide on further surgical tactics.
When the osteoma is anteromedial in relation to the condylar process, it is located in the region of the infratemporal fossa. Removing the tumor in this case is associated with significant difficulties, and sometimes even with a risk to the patient’s life. Chen Y. (2003) states that when the tumor is localized in the area of the articular process, in most cases its resection followed by arthroplasty and orthopedic treatment is indicated [8]. Other authors adhere to the same point of view, recommending combining resection of the condylar process with subsequent plastic surgery of the joint, lengthening of the ramus, combined operations on the upper and lower jaw to correct the bite and hardware treatment [4, 7, 18]. At the same time, the above observation indicates that in some cases it is possible and even necessary to remove the tumor while preserving the elements of the joint. This is also evidenced by the data of Piattelli A. (1995) and other authors [11, 13].
It should be noted, however, that when the osteoma is anteromedial in relation to the condylar process (according to the literature, this is the most typical localization), it is located in the region of the infratemporal fossa. This area is surgically extremely difficult to access and is located near vital structures, so removing the tumor in this case is associated with significant difficulties and sometimes even a risk to the patient’s life.
The main anatomical obstacles to reaching the infratemporal fossa are the zygomatic arch, the ramus of the mandible, the parotid gland and the facial nerve - formations that are extremely important in functional and aesthetic terms. Access to the tumor should be sufficient for its radical removal and provide a good overview.
Currently, a number of options for surgical access to the infratemporal fossa have been proposed, more or less satisfying these requirements, but not all of them are appropriate in the case of osteoma of the condylar process.
In 1961, JF Barbosa developed an approach to the infratemporal fossa, which involved performing a Weber-Fergusson incision followed by mobilization of the zygomatic complex and resection of the mandibular ramus [6]. DJ Crockett (1963), using a similar approach, limited the resection of the branch to the coronoid process only [10, 16]. This so-called anterior route is usually combined with maxillary resection and provides a wide view, but at the same time it is very traumatic and unfavorable from a cosmetic point of view. The infratemporal fossa can also be achieved by making a premaxillary incision followed by osteotomies of the mandibular ramus at various levels, rotation or removal of the bone fragment from the surgical site. In case of resection of a section of the branch, the latter can be returned to its place at the end of the operation and fixed in the form of a free autograft [16].
The main anatomical obstacles to reaching the infratemporal fossa are the zygomatic arch, the ramus of the mandible, the parotid gland and the facial nerve - formations that are extremely important in functional and aesthetic terms. In 1985, NR Attenborough proposed the use of a coronal approach to visualize the structures of the pterygopalatine and infratemporal fossa. This method involved making pre-auricular and semi-coronal incisions with subsequent removal of the zygomatic arch and coronoid process [5]. HL Obwegeser improved this technique by combining mobilization of the entire zygomatic complex with osteotomy of the coronoid process. In this case, the zygomatic bone was displaced downward on the fibers of the masticatory muscle, and the coronoid process was retracted upward [12]. In addition to the above, numerous modifications and combinations of access are used depending on the clinical situation [10]. As our experience shows, the use of coronary access is the method of choice when removing tumors localized in the infratemporal fossa. It provides a good overview and freedom of surgical manipulations, avoids injury to large vessels and branches of the facial nerve, and is also most cosmetically acceptable.
We also note that with long-growing bone tumors in the TMJ area, the joint can undergo significant morphofunctional changes that require postoperative orthopedic correction, however, as was shown in our observation, the compensatory capabilities of the joint are quite high, which in some cases with low-traumatic and radical removal tumor allows you to achieve restoration of function without additional measures in the postoperative period.
Thus, observation of the patient in the long term after surgery (9 years), indicating a relapse-free course and the absence of deep functional disorders, confirms the effectiveness of the approaches used to remove the TMJ tumor. Careful diagnosis and surgical intervention using approaches that provide wide access to the infratemporal fossa allowed for radical removal of osteoma of the condylar process of the mandible, while avoiding additional trauma to the anatomical formations of this localization, providing a quick postoperative recovery period and a satisfactory result for 9 years with complete restoration of TMJ function.