BONE PLASTICS

From Big Medical Encyclopedia

BONE PLASTICS (grech, plastike sculpture, plastics; synonym osteolasty) — the surgery made for recovery of an integrity or change of a shape of a bone, and also for the purpose of stimulation of regenerator processes in a bone tissue and connected with movement of own or alien bone fragments. There are three main types To. item: autoplasty (see), at a cut use own bones of operated; an alloplasty [the former term — homoplasty (see)] when use bones of other individual belonging besides to a look, and xenoplasty [the former term — heteroplasty (see) ] — change of the bone taken from an organism of another biol. look. To. the item can be free when the replaced fragment is completely separated from a maternal bone, and not free — the transplant keeps communication with a maternal bone. To. the item is applied: as independent operation with the purpose of compensation of defect of a bone, recovery of an integrity or change of a shape of a bone; for stimulation of bone regeneration as a component of the main operation, napr, as addition at a metalosteosynthesis; as combined To. the item when one bone transplant (usually hallo-) serves as the fixer of bone fragments, and the second (is more often auto-) is construction material for a callosity and a stimulator of bone regeneration.

Attempts of change of a bone tissue to the person were made in an extreme antiquity. Evidence-based plastic changes of a bone were begun in 19 rubles Walter (Ph. Walther, 1821) and Wolff (J. Wolff, 1863) reported about successful transplantation of bone fragments of a skull. Makjyuin (W. Macewen, 1882) removed almost all diaphysis of the humeral bone affected with osteomyelitis at the three-year-old boy. In two years the formed defect of a humeral bone was replaced with the allotransplant received from the amputated extremity of other patient. A. Ponce (1887) at treatment of a nearthrosis of a tibial bone made change of a phalanx of the thumb of foot taken from the amputated extremity.

A founder of osteoplastic surgery in our country is N. I. Pirogov who in 1852 made amputation of foot, having replaced to the resected joint surface of a tibial bone back department of a calcaneus together with soft tissues. The operation N. I. Pirogov laid the foundation for transplantation of a bone on the feeding leg.

In 1858 and 1867 there were pilot studies of L. Ollier devoted to free change of bone fragments. L. Ollier considered that the autograft begets, grows and functions in an organism. At the same time it attached a principal value to a periosteum, considering that at change of a bone without periosteum the transplant perishes. Also wrote about it in the works E. I. Bogdanovsky (1861) and I. A. Bredikhin (1862). A new stage of development of the doctrine about To. items were pilot studies of I. V. Radzimovsky (1881). He established that after change osteocytes perish, and the bone tissue resolves, being gradually replaced with a neogenic bone from the begot periosteum. At change of the bone deprived of a periosteum, process of regeneration happens, but more in a slowed-up way. In the experiences with change of dead bones I. V. Radzimovsky showed a role of a bone bed in regenerator processes. These important data were then are confirmed with Bart, Marchand, Akskhauzen's researches (A. Barth, G. Marchant, G. Axhausen), etc. B 1895 of Barth came to a conclusion that the replaced bones at any kind of plastics always perish entirely with the periosteum and marrow. Transplants gradually resolve and are at the same time replaced with a neogenic bone. Process of regeneration at the same time always proceeds from a bone bed and goes as the «creeping» gradual substitution of a devitalized bone tissue. The transplant actively does not participate in process of regeneration, and is an irritant for osteoblasts of a bone bed. Though these views of Bart were widely adopted, however his conclusions about full death of a transplant met objections. In 1909 in the works Akskhauzen claimed that at an autoplasty almost all bone tissue of a transplant gradually perishes, however at the same time cells of a periosteum and marrow keep the viability. They are also the main sources of a new growth of a bone. Akskhauzen considered therefore that the best material for bone plastics is the autograft taken with a periosteum and marrow. The dead bone tissue of a transplant resolves osteoclasts and is replaced with the neogenic ossiform fabric passing then into a bone tissue.

In 1910 — 1914 of H. N. Petrov, N. I. Bashkirtsev and A. A. Nemilov made experiments for clarification of a question of sources of regeneration of the replaced bone. According to these researches, at free plastics of bones gradually die off all elements of a transplant.

Take part in formation of a new bone as cellular elements of a bone bed and partly the transplant, and a cell of surrounding extra bone connecting bone tissue. The bone transplant, as a rule, is gradually replaced with the bone tissue coming from fabrics of a bed of the recipient, the transplant plays a role of a framework for this regenerate.

It is considered established that the bone tissue of a transplant at change though loses the osteocytes, but keeps the vital properties in the main substance which are shown in processes of a rassasyvaniye and creation. Fabric of a transplant, resolving, it is replaced with a neogenic bone. This process means not death of a transplant in the usual sense of this word, and its reorganization, i.e. process physiological. The regenerate evolving from a transplant is not its full copy. The form of a regenerate is defined funkts, features of area of transplantation. For auto-and alloplasties are characteristic the general patterns of regeneration, but at an alloplasty it proceeds more in a slowed-up way that is connected with need of overcoming immunol, incompatibility of fabric (see. Incompatibility immunological ). Therefore more favorable for To. items are autografts. Quicker than others the transplants rich with spongy fabric are reconstructed — use them preferential for stimulation of regeneration. The type of a transplant is defined by the purpose K. item. So, at treatment of nearthroses apply strong massive cortical transplants. Usually apply the fragmented transplants in the form of filling brick or shaving to substitution of bone cavities. Transplants take usually from a tibial bone, from a wing of an ileal bone less often from other bones. In spite of the fact that on biol, to properties the autoplasty is the best method, it cannot satisfy completely increasing requests of osteoplastic surgery because of the limited opportunities in sense of quantity, the sizes and forms of transplants. Therefore the increasing value in traumatology and orthopedics is gained by a bone alloplasty.

Ways of preparation and preservation of an allogenic bone tissue are studied in detail thanks to what allotransplantation was widely included into practice of osteoplastic surgery. Methods of preservation of transplants in fluid and dense mediums, preservation are developed by cooling, freezing, lyophilizing etc. (see. Conservation of bodies and fabrics ). The organization of bone banks for preparation and storage of allotransplants had great practical value. A certain distribution was gained by a kind of an alloplasty — brephoplasty (see).

Xenoplasty is applied extremely seldom. Xenogenic fabrics prepare for a wedge, is more whole from animals. Heterografts use in the form of the boiled-down, matserirovanny or tinned bone. Antigenic properties of xenogenic fabrics, as well as allotransplants, can be substantially weakened by conservation. Heterografts are also replaced with a neogenic bone, but this process lasts much longer, than at an autoplasty. In this regard the combination of slowly resolving heterograft as the fixer and more valuable in biol, the relation of an autograft is possible (if necessary).

Indications and Contraindications

Bone auto-and the alloplasty is shown at operational treatment of not accrete changes, nearthroses and defects of bones, during the carrying out front or back spondylodesis (see), artificial ankylosis (see), plastic surgeries on joints, at amputations and various reconstructive bone operations.

Substitution of the joint ends of bones of a diaphysis or entirely separate bones (e.g., at malignant tumors of the last) gained noticeable distribution that is connected with development of methods of preparation of bone allotransplants of the big sizes.

Contraindication for To. the item is existence of the accompanying inflammatory phenomena, skin defeats in a type of ulcers, furuncles, pyodermas etc. However To. the item is in certain cases used at operational treatment of osteomyelitis and the infected nearthroses.

The equipment

the General requirements imposed to technology of operation come down to a strict asepsis, care with fabrics, a careful stop of bleeding, the correct adjustment of a transplant for its dense contact with a bed of the recipient on perhaps bigger square, to a careful covering its soft tissues with layer-by-layer sewing up of a wound and imposing of a retentive bandage. Choice of a way K. the item is defined generally by features of local process.

Implementation in practice of ultrasonic tools for cutting and connection of bones considerably facilitated performance of many osteoplastic operations. By means of ultrasound became possible to prepare transplants and a bed for them any necessary form, and also to strongly connect bone fragments (see. Ultrasound in traumatology ).

Fig. 1. The scheme of plastics of a tibial bone at a nearthrosis the sliding transplant across Hakhutov: 1 — the bone plate (transplant) is cut; 2 — cross-section of a bone with a transplant; 3 — the transplant is turned on 180 ° (the crack of a nearthrosis is blocked by a transplant).

Plastics the sliding transplant across Hakhutovu the hl is produced. obr. at nearthroses of a tibial bone without diastase. From the anteriointernal surface of a bone after a slit of a periosteum a circular saw cut a wide bone plate of 15 — 20 and 1 — 1,5 cm wide (from both ends of a bone to the marrowy channel). After receiving a transplant countries of fragments are liberated from cicatricial fabric, the crack of a nearthrosis is filled with bone shaving. The transplant is turned on 180 ° (its distal end becomes proximal), blocking the place of a nearthrosis, and strengthen it catgut seams and if it is necessary, screws (fig. 1).

To plastic on Grevsa — Bruna apply at nearthroses with defect of a bone. After subperiostal allocation of fragments open marrowy cavities, fill bone defect with the transplant taken from a tibial bone together with a periosteum and a layer of spongy substance. The free space between fragments, besides, is filled with the bone shavings and splinters received during the processing of the ends of fragments. This operation is applied seldom.

Plastics according to Matti. At this look To. items make refreshing of the ends of fragments, open marrowy cavities and in fragments hollow out deep trenches 6 — 8 cm long. After comparison of fragments of a trench fill with spongy substance of a bone, taken from a big spit or from a tibial bone, and also the shavings received at formation of trenches.

Fig. 2. The scheme of plastics of a tibial bone at a nearthrosis according to Phemister: the transplant laid podnadkostnichno blocks a crack of a nearthrosis.

Plastics according to Phemister it is shown at fibrous nearthroses without the shift of fragments. Podnadkostnichno is released in a zone of a nearthrosis by fragments and, without breaking fibrous connection, stack a transplant, blocking a crack of a nearthrosis. The transplant is taken from a wing of an ileal bone or from a tibial bone (fig. 2).

Fig. 3. The scheme of plastics of a tibial bone at a nearthrosis a pristenochny transplant (1) with an intra bone metal core (2) across Bogdanov.

Plastics a pristenochny transplant across Bogdanov it is made in combination with metal osteosynthesis (see). Podnadkostnichno is allocated by the ends of the fragments making a nearthrosis, open marrowy cavities, compare fragments and fix them a metal pin vnutrikostno or a metal plate. After that stack on the refreshed side surface of both fragments auto-or allotransplant from compact substance of a bone and fix its catgut (fig. 3). This method is often applied at diaphyseal nearthroses without big shortening.

Kostno-nadkostnichnaya decortication Ollye was for the first time executed. It is widely applied in practice of traumatology and orthopedics, usually as addition to To. item in other ways. At the slowed-down consolidation and «hard» (slow-moving) nearthroses it can be used as independent operation. In a zone of a nearthrosis a chisel force down laminas of a cortical layer together with the periosteum covering them and muscles. Thus, around a zone of injury of a bone the bone and periosteal case with the kept vascularization and an innervation is created that provides favorable conditions for bone formation. After production of the main osteoplastic operation the wound is layer-by-layer sewn up.

Fig. 4. The scheme of intraekstramedullyarny plastics of defect of a tibial bone across Chaklin: 1 — an extramedullary transplant; 2 — an intramedullary transplant; 3 — defect of a bone.

The Intraekstramedullyarny plastics across Chaklin is applied to treatment of nearthroses and extensive defects of long tubular bones. Make economical refreshing of the ends of fragments and their comparison. The intramedullary transplant is taken from the proximal end of a tibial bone without periosteum, extramedullary — with a periosteum. The transplant without periosteum is driven in serially into a marrowy cavity of both fragments, and the transplant with a periosteum is stacked outside in the prepared bed and strengthened a catgut (fig. 4).

Bone plastics as a faggot. In 1961 M. V. Volkov offered a method of substitution of bone defects and cavities thin plates of the frozen cortical allogenic bone without periosteum, the catgut circular seams fixed with each other in the sheaf reminding a faggot.

Method of biostimulation across Zatsepin. In 1931 T. S. Zatsepin at children with effects of poliomyelitis applied a method which he called «biological stimulation» to acceleration of growth of an extremity. He drove in a pin from the boiled-down xenogenic bone into a big spit and into a distal part of a hip over condyles, considering that the bone transplant in the course of a rassasyvaniye causes the strengthened hyperemia increasing function of a rostkovy zone. The method was not widely used.

Not free plastics. (Tibial) or forearms (a beam bone) make not free change of one bone for substitution of defect of one of two pair bones of a shin in another. E.g., the Ghana method consists in substitution of defect of a tibial bone a fragment of fibular. After change the fibular bone is considerably thickened and performs function of a tibial bone. Operation is made in two stages. Bare a proximal fragment of a tibial bone and on its front surface hollow out the trench in which place the distal end of the fibular bone resected at the same level. The second stage make similar operation and on distal fragments of tibial and fibular bones.

Reconstructive bone plastics. To. the item is included a component into various reconstructive operations, napr, correction of deformations, substitution of the joint ends of bones, lengthening of an extremity, etc. Correction of deformation and lengthening of a bone make by means of distraktsionno-compression devices (Ilizarov, Dedova, Wasserstein's methods) or by means of various type of osteotomies (Bogdanov, Bogoraz, Shpringer's methods).

Fig. 5. The equivalent circuit of defect of a tibial bone in the distraktsionno-compression device, across Ilizarov: and — the initial position (1 — the line of an osteotomy of a proximal meta-epiphysis; 2 — two guides of a spoke for bringing down of an osteotomirovanny fragment of a tibial bone); — unwinding (the third ring for a compression in a zone of the former defect is imposed), the defect in the field of an osteotomy filled with a neogenic bone tissue it is shaded.

The method of substitution of defects of tubular bones by lengthening of one of fragments was offered by G. A. Ilizarov in 1967. It is based that gradual distraction of bone fragments activates bone regeneration on site of emergence a diastase. Make a slanting osteotomy of one of fragments, most often in the field of an upper metaepiphysis. The separated fragment is reduced in a zone of defect the directing spokes on 0,25 mm by 3 — 4 times a day to contact with the resisting end of fragment. After the end of distraction create a compression on a joint of fragments (fig. 5).

Operational lengthening of a shin by Dedova's method consists in a Z-about-miscellaneous lengthening of a calcaneal (akhillov) sinew, sinews long, short fibular muscles and a front tibial, slanting osteotomy of a fibular bone, a Z-shaped osteotomy of a tibial bone with fixing of bone fragments on the distraktsionny device of Gudushauri. Lengthening should be begun not earlier than 10 — 12 days after operation and to carry out it gradually. Upon termination of the period of stretching the extremity is fixed the same device within 3 months.

Wasserstein's method — distraktsionno-compression a method of lengthening of a hip or shin during the shortening of an extremity not less than 4 cm using tubular allotransplant. Operation is made in two stages. At first extend sinews of the functioning muscles, and then do a cross osteotomy of a femur and enter intramedullyarno a metal pin. By means of the distraktsionny device in 7 days after operation make distraction daily on 2 mm up to the size of necessary lengthening. At the second stage of diastases between fragments it is replaced with bone tubular allotransplant. On a transplant the longitudinal groove according to thickness of section of a metal pin is created previously. Fragments with a transplant subject compressions the same device.

Segmented osteotomy across Bogdanov consists in a multiple cross section of a bone, correction of deformation and fixing of bone fragments a metal pin which creates conditions for recovery of structure and a shape of a tubular bone.

The segmented osteotomy across Bogoraz is made in need of correction of shortening and a curvature of a hip. The femur is chreznadkostnichno cut two sections on slanting segments and then subject distractions by skeletal traction.

Shpringer's operation make for correction of big rachitic curvatures of a shin. Podnadkostnichno is bared and resect a tibial bone at top and bottom border of a curvature. The free fragment of a bone is taken out and sawn on segments 1 — 2 cm high. The fibular bone is crossed and the shin is leveled. In a periosteal case stack one by one bone segments to one line for what part of them turn on 180 °.

See also Distraktsionno-kompressionnye devices , Osteotomy , Organ and tissue transplantation .


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V. A. Chernavsky, A.S. Imamaliyev.

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