RU2195891C2 - Method for revascularization of a thigh bone caput at its vascular lesions - Google Patents

Abstract

FIELD: medicine, surgical traumatology and orthopedics. SUBSTANCE: one should conduct longitudinal skin incision and underlying tissues through the middle of a major trochanter along external femoral surface downwards. A wide femoral fascia is similarly dissected and its ends are shifted sidewards. Longitudinal femoral muscle is exfoliated. One should open subperiosteal extraarticular area of a thigh bone. A fixator is extramedullarly applied. One should carry out an extraarticular osteotomy by developing a diastasis between the fragments being equal to the thickness of a cortical wall. In case of altered cervico-diaphysial angle, angle of anteversion or their combination the fixator is fixed after altering the orientation of fragments, but with a diastasis between them for the value of a cortical layer. The method enables to prevent postoperational complications. EFFECT: higher efficiency of operation. 10 dwg, 2 ex

Description

 The invention relates to medicine, namely to surgical traumatology and orthopedics, and can be used in the treatment of vascular lesions of the femoral head of any etiology (osteochondropathy, Perthes disease, aseptic necrosis of the femoral head).

 Conservative treatment of vascular lesions of the femoral head in both sanatorium and outpatient settings is often accompanied by an unsatisfactory outcome (in 40.4 and 39.4% of cases, respectively), and with an outcome of 35-40 years old, a total of 70-75% is shown endoprosthetics (Divakov MG, Boloboshko KB "Long-term outcomes of conservative treatment of osteochondropathy of the femoral head". Bulletin of Traumatology and Orthopedics named after NN Priorov. 1999, 4, pp. 44-48).

 There is a method of treating vascular lesions of the head (Perthes disease), which consists in extraarticular (intersubtrochanteric) osteotomy of the femur (Andrianov V.L., Veselovsky Yu.A., Tikhonenkov E.S., Sadofieva V.I. "Traumatology and orthopedics". 1987, 10, pp. 40-44) with the aim of centering the head in the cavity with subsequent prolonged unloading of the operated joint (up to 16.6 months). This method is adopted as a prototype.

 However, the known method does not provide accelerated restoration of blood supply and the structure of the femoral head, which, depending on the extent of the lesion and the age of the patient, are delayed to 1-1.5 years.

 This is due to the fact that the height of the regenerate (callus) between osteotomized fragments is minimal and the formation of the vascular network in it is insufficient to ensure complete revascularization of the femoral head. In addition, the postoperative prolonged unloading of the ischemic joint, as the main component of surgical treatment, adversely affects the trophism of the epiphysis of the femoral head compromised by a vascular catastrophe (O. V. Dolnitsky, A. A. Radomsky, “Orthopedics, traumatology”, 1987, 10, p. 45 -48), expressed in the destruction of the acellular plate, the violation of its surface areas, an increase in the size of chondrocytes, razvolennost matrix, up to the replacement of its connective tissue.

 The purpose of the invention is to reduce the rehabilitation time and reduce the likelihood of postoperative complications.

 The goal is achieved by accelerating the restoration of blood supply to the femoral head by increasing the thickness of the inter-fragment regenerate after extra-articular osteotomy under conditions of extramedullary osteosynthesis.

 The essence of the invention lies in the fact that after intertrochanteric or subtrochanteric osteotomy of the femur between its fragments a diastasis is created equal to the thickness of the cortical wall of the sawdust region, followed by stable osteosynthesis.

The invention is illustrated using figure 1
In FIG. 1 shows the proximal femur in the frontal plane (front view) with the installed metal structure. The area of subtrochanteric osteotomy with the creation of diastasis between the fragments of the femur is shown.

 The periosteum is conditionally not shown.

 The proposed method is as follows.

 The patient is laid on the opposite side. A longitudinal incision is made of the skin and underlying soft tissues through the middle of the greater trochanter along the outer surface of the thigh down. A wide fascia of the thigh is dissected similarly, its edges are shifted to the sides. Exfoliate longitudinally the rectus femoris muscle. The subperiosteal intertrochanteric or subtrochanteric region of the femur is exposed.

A fixative is applied (Blount plate, L-shaped plate, AO plate, Trotsenko-Nuzhdin fixer, depending on the age of the patient) and fix it with screws to the femur. (1, Fig. 1) Using a Gigli saw or an oscillating saw, an extraarticular intertrochanteric or subtrochanteric osteotomy is performed with a cut equal to the thickness of the cortical wall of one of the adjacent femoral fragments in this region with the formation of diastasis to form a regenerate between fragments (2, Fig. .1)
In cases of changes in the cervical-diaphyseal angle, the angle of antversion or their combination, the fixator is fixed to the bone fragments after changing their orientation, but with the creation of diastasis between them by the size of the cortical layer. The wound is sutured in layers. Sutures are applied to the skin, aseptic dressing, and derotid gypsum boot.

 Bed rest is determined for 4 weeks. After this time, walking on crutches with a partial load on the operated limb is allowed. Walking with a full load on the operated limb using crutches is recommended 10-12 weeks after surgery with preliminary radiography of the joint concerned, regardless of the stage of the disease. In parallel, a muscle massage of the gluteal region and thigh, therapeutic exercises, electrical stimulation and swimming are prescribed to strengthen the muscles of the limb.

 Walking without additional support is allowed 3 months after the operation.

 An example of the practical application of the proposed method in Perthes disease.

 Patient S. Zhenya, born in 1989, was admitted to the orthopedic department. MSC "Mother and Child", Nizhnevartovsk, 1.02.97, with complaints of pain in the right hip joint. Considers herself a patient for 1.5 years, when, for no apparent reason, pain first appeared in the right knee joint, and then in the hip.

 An X-ray examination of 09/12/96 of the hip joints in the straight (Fig. 2) and axial (Fig. 3) joints revealed Perthes disease in the fragmentation stage. After the examination, the patient 02/05/97. was operated on by the proposed method: the application and fixation of the Blount plate on the proximal end of the femur, followed by posttrochanteric osteotomy and the creation of diastasis between the fragments on the thickness of the cortical layer of the adjacent fragment (Fig. 4). The postoperative period without features. 4 weeks after surgery, the patient is allowed to walk on crutches without loading the operated leg, after 10 weeks with a dosed load, and after 3 months with a full load. On the control x-ray of the right hip joint 4 months after surgery 13.06.97 marked consolidation of the osteotomy (figure 5), the restoration of the shape of the epiphysis of the femoral head. Lock removed. The function of the operated joint in full, no shortening. During follow-up 2 years after surgery, there are no complaints. The function of the operated limb is complete. On the control x-ray of the hip joints from 02/12/99 (Fig.6) there is a complete restoration of the structure of the femoral head on the right.

 The second example of the clinical application of the proposed method for aseptic necrosis of the femoral head.

 Patient B.I., 13 years old, and.b. 13762, entered the 11th orthopedic department of the Moscow City Clinical Hospital 59 in Moscow with complaints of constant pain in the left hip joint, limitation of movements in it, shortening of the limb.

 Considers herself ill since 1998, when 3 months after pain in the hip joint appeared pains that gradually intensified. Lameness and limb shortening joined. He was treated in the orthopedic department of the children's clinical hospital. No effect. Upon admission to the clinical hospital 59 revealed that the patient walks on crutches, loading the front of the foot. The movements in the left hip joint are sharply limited: flexion to 110, extension 140, no rotational movements. The shortening of the lower extremity is 4 cm. On the radiograph of the left hip joint (Fig. 7), aseptic necrosis of the femoral head with impression of the upper-outer segment is determined. The joint gap is sharply narrowed. Spotted osteoporosis of the neck and trochanteric region. Subtrochanteric valgus osteotomy was performed on the patient January 15, 1999 with the formation of a wedge-shaped diastasis between the fragments (Fig. 8), which eliminates limb shortening. The postoperative period without features. The load is allowed 2 months after the operation: at first partially, and after 3 months full. Clinical and radiological examination 7 months after the operation (08.19.99) revealed a complete restoration of the function of the hip joint with the elimination of shortening of the limb. On the x-ray of the left hip joint (Fig.9) is determined by the complete consolidation of the osteotomy. Lock removed. During the follow-up examination after 11 months (12.24.99) after the operation, he considers himself to be absolutely healthy. On the x-ray of the left hip joint (Fig. 10), the head of the femur is of the correct form, is in the valgus position, the joint gap is slightly narrowed. There are no signs of vascular disorders in the femoral head.

 The proposed method is intended for use in hospitals with an orthopedic and traumatic profile in the treatment of vascular lesions of the femoral head of any etiology.

 Its use can significantly reduce the rehabilitation period while reducing the likelihood of postoperative complications.

Claims (2)

 1. The method of revascularization of the femoral head with its vascular lesions by its extra-articular osteotomy, characterized in that between the fragments of the osteotomy bone create diastasis the thickness of the cortical layer of the adjacent bone under conditions of stable extramedullary osteosynthesis.  2. The method according to p. 1, characterized in that in cases of changes in the cervical-diaphyseal angle, the angle of antversion or their combination, the fixator is fixed to the bone fragments after changing their orientation, but with diastasis between them also by the size of the cortical layer.

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