RU2163101C1 - Surgical method for treating lower extremity deformities in children having diastrophic dysplasia - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves concurrently applying tenomyotomy of subspinal and adductor muscles, intertrochanteric osteotomy, epicondylic osteotomy of the femur and knee pan transfer. Single lateral access is carried out for moving the kneepan and making osteotomy from the greater trochanter to tibial tuberosity. EFFECT: accelerated treatment course; coordinated muscle function restoration. 6 dwg

Description

 The invention relates to medicine, namely to traumatology and orthopedics, more specifically to pediatric surgical orthopedics.

 Surgical treatment of diastrophic dysplasia (DD) is characterized by complexity, duration, multi-stage due to the severity and prevalence of osteoarticular lesions, as well as the characteristics of extra-skeletal manifestations of the disease.

In addition to dwarfism and various skeletal deformities, DD is characterized by their rapid progression in the spine and large joints due to a genetically determined developmental disorder of the pineal gland. (M.V. Volkov, E.M. Meerson, O. L. Nechvolodova, L. I. Samoilova, G. P. Yukina Hereditary systemic diseases of the skeleton. M., Medicine, 1982. - P. 82 - 91)
Surgical interventions aimed at correcting the above deformations are widely known benefits and constitute a complex of operations on soft tissues (tenomyotomy of the subspinal and adductor muscles, Foss, Ru-Friedland-Volkov, Sturm, Zatsepin and others) and corrective osteotomies (such as Kochev , Repke, Vredena et al.) Or bone resection in combination with bone or intramedullary osteosynthesis (I. A. Movshovich. Surgical orthopedics. - M .: Medicine, 1994. - 446 p .; Traumatology and orthopedics, Manual for doctors in 3 then ah, edited by corresponding member of the Russian Academy of Medical Sciences Yu. G. Shaposhnikov, M.: Medicine, 1997. - Volume 3. - 623 p .; MP Konyukhov, Yu.A. Lapkin, OK Evdokimov. Surgical correction of foot deformities patients with systemic pathology // Actual issues of pediatric traumatology and orthopedics, S - Pb., 1993. - P. 142-143). These methods are taken by us as a prototype.

 It is known that sequential, stage-by-stage correction of constantly recurring (until the patients' growth is over) deformations implies their frequent operation and determines the duration of treatment, delaying the medical, psychological and social rehabilitation of these patients (M.V. Volkov, A.G. Pechersky, E. P. Mezhenina, Epiphyseal dysplasia in children and adolescents, Kiev: 3dorov'ya, 1977. - 127 p.). Therefore, the question remains open whether it is possible to accelerate the time of this rehabilitation.

 In order to search for methods that can reduce these periods, we have developed and implemented a “method for the surgical treatment of lower limb deformities in children with DD,” the essence of which is a one-stage correction of flexion-causing contracture of the hip joint, flexion contracture of the knee joint, and correction of the dislocated patella, allowing not only combine 4 operations in 1 stage, but also thereby create the conditions for the simultaneous coordinated restoration of muscle function of the operated limbs, then also contributes significantly accelerate the treatment of patients. This item requires some explanation. In sequential operations on prototypes, after correction of one deformation, muscles cannot be included in the full-fledged rehabilitation process with the help of passive and active movements because all the muscles involved are bilartic and their orientation is violated by the remaining deformation. When performing our method, we simultaneously correct the axis of the limb, the muscles acquire the correct orientation and their rehabilitation becomes possible.

Thus, we formulated a new problem and proposed its successful solution, leading to a qualitatively new result, consisting in:
1 - to prove the feasibility, safety and feasibility of performing a large volume of interventions for DD in stage 1;
2 - in providing conditions for the simultaneous coordinated restoration of muscle function of the operated limb;
3 - to reduce treatment time. If, when performing sequential operations on prototypes, treatment took from 11 months to 1 year, then our method reduces these periods to 6 months.

 In the list of figures indicate the scheme of the method and the stages of its implementation.

In FIG. 1 shows a diagram for the elimination of flexion contracture of the hip joint by performing intertrochanteric osteotomy or sphenoid bone resection with the base of the wedge along the posterior thigh;
In FIG. 2 shows a diagram for eliminating the resulting contracture of the hip joint by performing an intertrochanteric osteotomy or sphenoid bone resection with the base of the wedge along the outer surface of the thigh;
In FIG. Figure 3 shows the scheme for elimination of flexion contracture of the knee joint by supracondylar osteotomy or wedge-shaped resection of the bone with the base of the wedge along the front surface of the thigh or by introducing a proximal fragment into the prepared bed along the front surface of the distal fragment (lateral projection);
In FIG. Figure 4 shows the scheme for eliminating flexion contracture of the knee joint by means of a supracondylar osteotomy or wedge-shaped resection of the bone with the base of the wedge along the front surface of the thigh or by introducing a proximal fragment into the prepared bed along the front surface of the distal fragment (direct projection);
In FIG. 5 shows a diagram of the finally corrected axis of the limb by intertrochanteric and supracondylar osteotomy with osteosynthesis by the Bogdanov intramedullary shaft;
In FIG. Figure 6 shows the pattern of moving the patella to the physiological position by the operation of Ru - Friedland - Volkov.

 The method is carried out as follows.

 Under endotracheal anesthesia, in the position of the patient on the back, after treating the iliac region and the affected limb with iodonate, we perform tenomyotomy of the subspinal and adductor femoral muscles according to the classical method. After suturing the wounds, we turn the patient over to the “healthy” side and perform an incision starting from a large trochanter down the outer surface of the thigh and bending around the knee joint outside, ending it 2 cm below the tuberosity of the tibia on the anterior surface of the tibia. Dissect the skin and subcutaneous tissue in layers. We cut the fascia of the thigh from the upper corner of the wound 10-15 cm down, temporarily cover the rest of the section with a napkin. With a wide raspator, we longitudinally dissect the soft tissues to the bone and subperiostally expose the intertrochanteric region of the femur. Holding soft tissues with elevators, a chisel or an oscillating saw, we perform a transverse osteotomy. From the proximal fragment, we select a bone fragment of a wedge-shaped or trapezoidal shape with the base posteriorly and outward by an amount corresponding to the initial flexion (Fig. 1) and leading (Fig. 2) contracture with the calculation of the complete elimination of muscle tension. Through the center of the sawdust of the proximal fragment, we retrogradely insert the intramedullary rod of Bogdanov or CITO pre-selected according to the length of the bone and the diameter of the bone marrow canal and bring it to the surface of the skin through 1.5 cm contraperture. We compare the proximal and distal fragments of the femur and push the fixator into the bone the cerebral canal to n / 3 of the femur (Fig. 3). We cover the wound with a napkin, we impose suggestive sutures to the b / 3 hips and proceed to eliminate the flexion contracture and deformation of the knee joint. We dissect the fascia in the supracondylar region to a length of 7-10 cm, bluntly exfoliate m.vastus lateralis, expose the supracondylar region and perform transverse femoral osteotomy subperiostally under the cover of elevators. During extension of the contracted knee joint, the sawdust of the distal fragment is shifted downward. To adapt the fragments, we excise the wedge from the distal fragment with the base anteriorly or (with a significant displacement) with a bit, form a bed in it along the front surface at the edge of the sawdust (Fig. 4) and, comparing the fragments, perform osteosynthesis with antegrade advancement of the rod into the epiphysis of the femur (Fig. 5 )

 The last step is to carry out the movement of the patella typically, according to the method of Ru - Friedland - Volkov (Fig. 6).

 We complete the operation by applying a hip gypsum dressing in the position of full extension in the hip and knee joints and the maximum possible abduction of the hip.

 Thus, for the first time, we proposed a method for simultaneously eliminating the flexor-leading contracture of the hip joint, flexor contracture of the knee joint and dislocation of the patella in children with DD and performed this operation using long access from the greater trochanter to the tibial tuberosity, achieving the stated result, significantly reducing terms of treatment of the patient. We have shown the practical feasibility of this method and its clinical utility in the experience of treating 3 patients.

Claims (1)

 A method for the treatment of diastrophic dysplasia, including four operations, namely, tenomyotomy of the subspinal and adductor muscles, intertrochanteric osteotomy, supracondylar osteotomy of the femur and patellar movement, characterized in that all these operations are performed simultaneously, while for osteotomy and patella movement one lateral access is performed from the greater trochanter to the tuberosity of the tibia.

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