RU2068663C1 - Method for substituting femur head defects - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves using inferointerior portion of the femur head as osteochondrous autograft totally resected after performing necrectomy stage. The so produced graft is to be set into the maximum-load-bearing superior portion of the femur head. Resected inferointerior femur head portion is carried out by forming bone bed in subcapital portion of the femur neck with big graft exsected from patient iliac bone wing. EFFECT: wider range of applications.

Description

 The invention relates to medicine, and more specifically to surgery of the joints, and can be used to restore support and mobility in the hip joint in patients with extensive destructive foci in the most loaded parts of the femoral head.

 The analogues of the proposed method are as follows: The method of F.R. Bogdanov, in which the defect of the upper third of the femur, including its head, is replaced by the calcaneus (Bogdanov F.R. Osteosynthesis and bone grafting with pseudarthrosis and defects of long tubular bones after gunshot fractures questions reconstructive surgery, traumatology and orthopedics. Sverdlovsk, 19510 volume III, p. 15); Method of S. M. Voronchikhin replacement of a defect in the femoral head with a bone-cartilage autograft taken from the talus (Voronchikhin S. M. Issues of reconstructive surgery, traumatology and orthopedics. Sverdlovsk, 1959, Volume UII, pp. 158-159); The method of Biezalski J. (Biesalski Jü, 1910) replacement of an ankylosed hip joint, including its head with the lower third leg and talus (cited by A. S. Imamaliev Homoplasty of the joint ends of bones. M. 1975, p. 70).

 However, with the above methods, they cause significant irreversible damage to another composition, which is the main obstacle to the use of these methods in the clinic. The authors used these methods only in those rare cases in which pathology in the hip joint was combined with severe diseases of the lower extremity, causing the need to amputate the lower third of the leg or ankle joint arthrodesis.

 Another analogue of the proposed method is the Putti method (Putti, 1992) (Boychev B. Conforti B. Chokanov K. Operative orthopedics and traumatology. Sofia, 1961, M. p. 504).

 In this method, the absent head and neck of the femur are replaced with a bone-cartilage autograft representing the upper quarter of the fibula.

 One of the significant drawbacks of this method, as well as all of the above, in which autoplastic replacement of a defect in the articular end of the hip joint is performed, is the permanent loss of a healthy joint end of the bone to the patient, in this case the fibula.

 Another significant drawback of the Putti method is that it does not create an anatomical and functional correspondence between the joint ends of the bones of the hip joint, since the replaceable femoral head differs sharply in shape, size, cartilage and bone structure from the transplanted autograft taken from the fibula bones. The indicated complete anatomical mismatch of the two joint ends of the joint formed in this way will inevitably lead to its functional inferiority.

 The closest analogue of the proposed method is a method of replacing defects of the femoral head, developed by one of us (I.G. Marakusha - Copyright certificate N 1161096) prototype. I. (I.G. Marakusha Method for the replacement of defects in the femoral head with bone-cartilage autografts. Guidelines, L. 1985, 17 pp.).

 2. I. G. Marakusha Bone-cartilage joint autoplasty. Act speech at the enlarged meeting of the Academic Council of the Leningrad GIDUV dedicated to the 102nd anniversary of the founding of the institute. L. 1987, 17 pp.). The essence of the proposed method is that after removal of pathological foci, which are usually located in the most loaded upper parts of the femoral head, a bone-cartilaginous autograft is excised from the lower unaffected section of the same articular end of the bone. Then, the postoperative defect in the femoral head is replaced with an autograft. A bone-cartilaginous allograft is transplanted into a defect formed at the site of autograft excision. In this way, the entire articular surface of the superior epiphysis of the femur is restored.

 This prototype method compares favorably with these analogues in that it is not accompanied by the destruction of other joints of the patient and at the same time allows the defect to be replaced in the most abdominal part of the femoral head with a bone-cartilage autograft.

 However, this method can be applied mainly with limited focal lesions of the femoral head in the absence of its extensive lesion. It is not possible to implement bone-cartilaginous autoplasty of the femoral head with the above method if there are large foci in it, after removal of which only the lower-internal and partially marginal sections remain from the head.

 The aim of the invention is to expand the indications for the use of bone-cartilaginous autoplasty techniques in patients with extensive postoperative defects of the loaded part of the femoral head.

 The essence of the invention lies in the fact that the bone-cartilage autograft required to replace an extensive defect in the upper part of the femoral head is obtained by resection of the entire lower-inner part of the femoral head. To replace the donor site in the head, a massive bone autograft is used, excised from the ridge and wing of the patient’s pelvic bone. To fix the bone autograft in the lower subcapital section of the femoral neck, a bone bed is formed into which the distal end of the transplanted bone is immersed. A defect in the pelvic bone that occurred at the site of excision of the bone autograft is replaced with a spongy bone allograft freed from the bone marrow with a saline stream (method by E.N. Bellendir and I.U. Salmagambetov, 1986).

 The method is as follows: the patient is in a supine position. Anesthesia endotracheal ether-oxygen using muscle relaxants. The approach to the hip joint is made from Smith-Petersen access in the modification of P.G. Kornev. After dissection of the joint capsule and adhesions between the joint ends of the bones, a dislocation of the femoral head from the acetabulum is performed.

 Recall that the operation is performed for patients with large lesions in the femoral head. After removal of these foci within healthy tissues, an extensive postoperative defect arises in the femoral head: only the lower-internal and marginal departments remain from the head. The entire remaining lower-inner part of the femoral head is resected, which is subsequently used as a bone-cartilage autograft transferred to the most supportive upper part of the head. To restore the integrity of the donor site of the lower-inner part of the femoral head, a bone autograft is excised from the wing and ileum crest of the patient; for this purpose, those portions of the ilium that have the most pronounced spherical surface are used. The length of the bone autograft is on average 4-6 cm, and the width is 3-4 cm in the proximal and 2-3 cm in the distal. The specified transplant with a narrowed distal end is introduced into the bone bed, previously formed in the lower subcapital section of the femoral neck. The rest of the transplanted bone graft makes up for almost the entire lower-inner hemisphere of the femoral head. After the integrity of the lower-inner part of the femoral head is restored, the defect is replaced in its central-upper parts in the following sequence. A bone autograft obtained from the wing and ilium crest is immersed in the deep section of this defect. The size of this graft is on average 2 cm in diameter. A bone-cartilage autograft representing the lower-inner part of the femoral head is transplanted into the remaining unsubstituted surface section of the defect facing the joint cavity. The area of the cartilaginous cover of the indicated transplant, facing the joint cavity, is on average 405 cm • 3 cm, the thickness of the spongy base varies from 1 to 2 cm. The edges of the bone-cartilaginous autograft are in close contact with the remnants of the preserved external parts of the femoral head and transplanted into the lower its internal department is a bone autograft. The lower section of the bone-cartilage autograft is adjacent to the bone autograft located under it, which fills the central lower part of the defect.

 Since this method of operation requires the collection of large areas of bone tissue from the pelvic bone, the defects formed in it are filled with plastic material. Such is a bone spongy allograft, freed from the bone marrow by a stream of physiological saline according to the method of E.N. Bellendir and I.U. Salmagambetov (I.U.Salmagambetov Mono-and multicomponent alloplasty in reconstructive surgery of bone-articular tuberculosis. Abstract of the dissertation of doctor honey. Sciences, L. 1986). The specified allograft in shape and size corresponds to a defect in the ilium and completely replenishes the latter. If necessary, use several allografts.

 During the operation, hemostasis is performed. The femoral head is immersed in the acetabulum. A polyethylene drainage is introduced into the joint cavity. The surgical wound is sutured in layers before drainage. The postoperative period is carried out mainly in the same way as after the method previously proposed by one of us for bone-cartilage autoplasty of defects in the femoral head (I.G. Marakusha Method for replacing defects in the femoral head with bone-cartilage autografts. Methodical recommendations, L. 1985 , 17 pp.).

 An example of a specific implementation of the proposed method can serve as the following clinical observation.

 Patient P. 34 years old, (source. Bol. N 1567), was admitted to the hospital with a diagnosis of aseptic necrosis of the head of the right femur. The disease is 2 years old. During this period, conservative treatment was carried out. At admission, he complained of pain and restriction of movement in the joint, as well as a significant decrease in limb support ability. X-ray in the head of the femur is determined by the site of aseptic necrosis, spreading almost throughout the head. On February 5, 1988, the patient underwent an operation during which the focus of destruction was excised within the limits of healthy tissues. After that, an extensive defect appeared in the femoral head — only the lower-inner and partially marginal parts of the indicated articular end of the bone remained. To restore the femoral head, the following was done.

 In order to obtain a bone-cartilage autograft, the preserved lower-inner part of the femoral head is completely resected. To restore the donor site, a bone bed was formed in the lower subcapital section of the femoral neck, into which the distal end of the bone autograft, excised from the crest and iliac wing, is immersed. The length of the indicated graft was 6 cm, the width in the proximal part was 4 cm, in the distal 3 cm. A bone autograft obtained from the ilium was transplanted into the central part of the head, its size was 2.5 cm • 2 cm. The upper part of the defect, facing into the joint cavity, is replaced by a bone-cartilage autograft, which is a resected lower-inner part of the femoral head. The cartilage area of this transplant is 4.5 • 3 cm, the thickness of the spongy base is 2 cm.

 Defects at the site of excision of bone autografts in the wing and ilium crest are filled with two spongy bone allografts freed from the bone marrow, corresponding to the size and shape of the defects.

 There were no complications in the postoperative period. 4 years after surgery, the general condition of the patient is good. The operated limb is in the correct position. The range of motion in the joint is satisfactory; rotation movements are somewhat limited. It goes without additional support. Pain in the joint occurs only after a long walk, at rest they pass. Radiologically determined fusion of the bone bed with transplanted grafts. No gaps between the grafts can be traced. In the femoral head, areas with a discharged bone structure are revealed. The joint gap is determined throughout.

 The given clinical observation confirms the effectiveness of the proposed method of operation, which we used in 12 patients. Good treatment outcomes were obtained in 10 patients, satisfactory in 2 patients.

 The above method allows you to expand the indications for osteo-cartilaginous autoplasty, to use this method with the most extensive defects in the femoral head, which previously was not possible with the desired effect. The method can be applied for aseptic necrosis of the femoral head, tuberculosis and osteomyelitis of the hip joint.

Thus, the main distinguishing features of the proposed method in comparison with the prototype are as follows:
1. The proposed method in comparison with the prototype is designed to perform bone-cartilage autoplasty with more extensive destruction of the femoral head. In order to accomplish the task, the proposed method uses a larger bone-cartilage autograft, which is obtained by resection of the entire lower-inner part of the femoral head, and not part of this department, as provided in the prototype.

 After a complete resection of the lower-inner part of the femoral head in the proposed method, the technique of the indicated donor part of the femoral head is complicated in comparison with the replacement prototype; it is required to use a larger and more reliable transplant from the point of view of its reconstruction. Such in this method is not an allogeneic bone-cartilage graft (prototype), but a large bone graft excised from the crest and iliac wing of the patient. Reliable fixation of the specified bone autograft in this method cannot be carried out, as is done in the prototype, by immersing it in a defect at the site of the excised bone-cartilage autograft in the lower inner part of the femoral head in the form of the absence of the latter, since this department is completely resected.

 Unlike the prototype, in the proposed method for replacing the donor site in the said section of the femoral head, a bone bed is formed in the neck of the femur into which the distal end of a large bone autograft is implanted, which ensures strong fixation of the entire graft, including that part of it, which makes up for the spherical surface of the lower inner part of the femoral head.

 In contrast to the prototype, the proposed method of surgery involves the replacement of defects in the ilium at the site of excision of bone autografts.

Claims (1)

 A method for replacing defects in the femoral head by excising the damaged part of the bone, moving the formed bone-cartilage autograft and covering it with a head defect, characterized in that the entire lower-inner part is resected, which is moved to the defect at the site of the removed destruction site in the upper part of the femoral head, the donor site in the femoral head is replaced with a bone autograft from the ilium, the fixation of which is carried out by immersing its distal section in the bone bed, ized in the lower subcapital department of the femoral neck, the donor site in the iliac bone at the site of excision of a bone graft substitute for cancellous bone allograft released from the bone marrow.