RU2238688C1 - Surgical method for treating pathological femur dislocation accompanied with head and neck osteolysis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out single-step trochanter arthroplasty via two accesses. Cotyloid cavity is freed in the anterior part of access. Muscles are separated and longitudinally cut from greater trochanter apex. Apophysis cartilage is spherically modeled. Femur is transected in subtrochanteric area retaining proximal splitter connection to muscles. They are perforated as a window under the middle gluteal muscle. Femur reposition into cotyloid cavity is carried out through the opening. Proximal fragment is rotated in three planes to achieve greater trochanter apex centering in acetabular fossa. Lesser trochanter area is deprived of cortex from lower part of the proximal femur fragment. Fractured bone fragments end-to-side osteosynthesis is carried out using L-shaped plate at an age-specific angle. Muscles mobilized together with periosteum and broad tensor muscle femur fascia lata are transferred to end face part of bonesaw line. Supra-trochanteric plastic bone osteotomy is carried out in two stages when treating reduced cotyloid cavity.

EFFECT: enhanced effectiveness of treatment; stable position of greater trochanter apex and its centering.

2 cl

Description

The invention relates to medicine, in particular to orthopedics and traumatology, and can be used to restore the ability and function of the hip joint in childhood with pathological dislocation of the hip with osteolysis of its head and neck.

Such destruction of the neck and femoral head occurs as a result of epiphyseal osteomyelitis or aseptic necrosis of the head transferred in early childhood with undiagnosed and improperly treated congenital dislocation of the thigh, during dystrophic processes in the head and neck region of a different origin.

Restoring good function of the hip joint in such cases is achieved with great difficulty. The usual way out in such cases is arthroplasty of the hip joint with a large skewer (Colonna P. // J. Bone Jt. Surg., 1935. - Vol. 17., p. 110). However, muscle biomechanics was practically not taken into account, and joint ankylosis often developed. An attempt to arthroplasty with a small skewer, which does not correspond to the shape of the acetabulum, yields to a large skewer in the abilities of the support, also allows for less mobility of the joint.

Similar methods are those in which a hip osteotomy is performed in the undertrochanteric region with a bone wedge resection, then the proximal femur fragment is tilted (F.R. Bogdanov, G.N. p. 123-131; Heyn W. Trochanterplastik ein neues Verfahren zur operativen Behandlung veralterter Schenkelhalsbriiche // Zbl.chir. 1947. Bd. 72, No. 5. S. 531-536). Moreover, for the prevention of ankylosis, such operations are performed in two stages, preparing the shape of the acetabulum using a “prosthesis” of the hemisphere type (G.A. Bairov. A new method for surgical treatment of destructive pathological dislocation of the thigh in children. 1 Congress of traumatologists-orthopedists of the USSR, M., 1963 , p. 95; M. L. Dmitriev, G. A. Bairov, K. S. Ternova, L. V. Prokopova, Osteoplastic surgery in children. - Kiev, 1974. - S. 269-272). These operations also do not take into account the biomechanics of the distribution of centering muscle influences, the individual norm of the cervical-diaphyseal angle, the need for multi-plane mutual adaptation of fragments moved after osteotomy.

The closest analogue in this area is the method (prototype) of the operation according to De Palma (1951), in which, after an postoperative osteotomy, a proximal fragment with a large trochanter is inserted into the acetabulum and fixed with a two-bladed nail. This requires cutting off the muscles, which are then transplanted onto the diaphysis (De Palma AF An Improved Type of Arthroplasty of the Hip Joint // J. Bone Joint Surg. 1951. Vol. 33A, N 4. P. 437-446; A.M Sokolovsky, OA Sokolovsky. Pathological dislocation of the thigh. Mon. - Minsk, 1997. - p. 76-77).

The method does not take into account the stabilizing effects of the periarticular muscle groups, requires cutting off the muscles, does not achieve optimal fragment fragmentation for consolidation and biomechanics, and the disadvantages of modeling a rotated trochanter often require the use of vitalium caps. Also, the need for correction of the acetabulum, which undergoes reduction in such cases, is not taken into account.

The invention is aimed at solving the problem: increasing the efficiency of the method of trochanteric plasty for osteolysis of the head and neck of the thigh and pathological dislocation by substituting the restoration of the optimal anatomical and functional ratios in the hip joint.

When performing the proposed method, they achieve increased stability of the position of the top of the greater trochanter in the acetabulum with sufficient mobility, create a musculoskeletal model that is closest in biomechanical characteristics and shape to a healthy joint, provides reliable centering of the top of the greater trochanter and good consolidation of fragments after osteotomy.

This is achieved by one-stage trochanteric arthroplasty through 2 accesses, release of the acetabulum from the scars to expose the cartilaginous surface in the front of the access, exfoliation and partial longitudinal dissection in the rear of the access behind the broad fascia of the thigh together with the periosteum of the muscles from the apex of the greater trochanter, spherical modeling of the cartilaginous part its apophysis, crossing the thigh in the undertrochanteric region at a distance equal to the shoulder arm of the neck and head of the healthy side, preserving the connection of the proximal fragment with muscles, perforating them in the form of a window under the middle gluteus maximus muscle, performing reposition through this hole spit into the acetabulum, rotating to better adapt the proximal fragment in three planes until the vertex is centered in the acetabular fossa, the trochanter is located downward and the lower part is decorticated thigh, synthesis of fragments with a L-shaped plate end to side at an angle equal to the individual or age norm of the cervical-diaphyseal angle, transposition to the end part of the bone sawdust ovannyh together with the periosteum and muscles tensor fasciae latae muscle, of the under-developed at the outer edge of the acetabulum in 1 or 2 stages nadvertluzhnoy osteoplastic osteotomy.

The method is as follows. Perform curly S-shaped access, reminiscent of Smith-Petersen access. Upon access, the skin and subcutaneous tissue are dissected, then the front part of the access is carried out along the front edge of the tensioner of the broad fascia of the thigh, and the posterior part along the posterior edge of the stretching of this muscle. In the front of the access, the acetabulum is exposed from the scars to the cartilaginous surface, preparing it for reposition. The posterior external longitudinal section is partially exfoliated with the periosteum of the muscle from the apex of the greater trochanter, and the apophysis is given a spherical or ovoid shape. In the undertrochanteric region, the diaphysis of the femur crosses in the transverse direction, and the level of the cross section is selected at a distance from the apex of the greater trochanter, equal to the shoulder of the lever of the head and neck of the thigh of the healthy side or an approximate age norm for that. Cicatricial tissue and displaced muscles are perforated, a window is created under the middle gluteus muscle and the tensor of the broad fascia of the thigh, the proximal fragment is rotated in 3 planes, the tip of the greater trochanter is adjusted and adapted to the acetabulum until the “suction effect”. A portion of the small trochanter is decorticated with a portion of the adjacent diaphysis to ensure good mutual bone contact of the fragments. Fragments are synthesized by a L-shaped plate or its analogues (Kretschmar plate, Blount plate) end to side at an angle equal to the individual or age norm of the cervical-diaphyseal angle. The sharp branch of the plate is inserted along the diaphysis of the femur in the proximal direction, and the distal fragment is brought to the prepared area of the small trochanter and the diaphysis of the proximal fragment, the distal fragment is medialized, ensuring that the fragments contact end to side. To the end part of the bone filing of the proximal fragment, the muscles and tensioner of the broad fascia of the thigh are mobilized partially mobilized together with the periosteum. In the case of a reduced acetabulum, the supraclavicular osteotomy of the pelvis is performed by the same or subsequent stage into the ileal bone fissure, a bone graft from the iliac crest is inserted, free or on the muscle leg. The directed spit and, if necessary, fragments of the pelvis are fixed with knitting needles, continue unloading on skeletal traction and (or) the limb is fixed in a gypsum or polymer hip bandage. In the process of loading, the cartilaginous part of the growing apophysis experiences functional restructuring, adapts to the acetabulum.

Example 1. Patient M., 8 years old. History No. 213. When contacting the hospital, pronounced gait disturbances, relative shortening of the right lower limb were revealed. The great trochanter of the right thigh is displaced upward, leading and rotational contracture of the right thigh, severe lameness. A history of osteomyelitis of the proximal femur in 1 year of life. A high displacement hip dislocation was diagnosed on a radiograph, a large trochanter with a clearly visible growth area is displaced upward with an emphasis on the ilium wing. Neoarthrosis formed at the site of contact; there is no head and femoral neck. Diagnosis at admission: Destructive dislocation of the right thigh. The outcome of osteomyelitis of the proximal femur with complete osteolysis of its head and neck. Operated. The operation was performed according to the proposed method. Repositioned arthroplasty of the right hip joint was performed by apophysis of the greater trochanter, correcting the centering osteotomy of the right thigh. Pelvic osteotomy on the right. The following features of surgical intervention are noteworthy. In surgery, the joint cavity is freed from scars and bone-cartilage residues of the lysed femoral head. A groove was made in the distal fragment in the form of a recess for adaptation with a small trochanter having the shape of a ridge, and decortication was performed at the site of contact on the proximal fragment. The jaw of the Blount plate was introduced into the bone marrow channel of the proximal fragment, additionally fixing it with a screw through a small skewer into the distal fragment in order to prevent biasing forces. Reposition was achieved, while the muscle leg on the proximal fragment was preserved, rotating the top of the greater trochanter during reposition. The operation was supplemented by transposition of the iliopsoas muscle onto the anterior surface of the proximal fragment. An over-acetabular osteotomy of the pelvis was performed with the placement of 2 bone grafts from the resected part of the thigh; the acetabular part was tilted anteriorly and outwardly. Transcutaneous fixation with needles temporarily, skeletal traction. On the histology of distant parts of the head from the cavity: pronounced dystrophic changes in the cartilage tissue. Metalwork removed 10 months after surgery. 1 year after the operation, the load is allowed. After 1.5 years, when viewed, the hip abduction is up to 60 degrees, the amplitude of the rotational movements is 50 degrees. On the roentgenogram, a large trochanter is centered in the acetabulum, the cervical-diaphyseal angle is maintained at an angle of 130 degrees. Shortening to 3 cm compensates with a heel, walks without additional means of support.

Example 2. Patient K., 2 years 3 months. History No. 700. He was diagnosed with a pathological dislocation of the left thigh of a destructive type. A history of osteomyelitis. Arthrography with double contrast revealed signs of true anatomical irreducibility. Performed repositional trochanteric arthroplasty according to the proposed method. After osteotomy, the reduction of the greater trochanter to the hip joint, the surface of which is exposed to the cartilage, is achieved. The femoral head and neck are fully lysed. The cartilaginous areas of the lesser trochanter and stump of the neck were found, however, these sites were found unsuitable for reposition. The spherical part of the apophysis of the thigh is highlighted in the back with the preservation of a good muscle leg of the middle gluteal muscle. An osteotomy was performed at the level of v / 3 of the diaphysis, while the length of the proximal fragment corresponded to the length of the neck and head lever from the healthy side. At the same time, the connection with the muscle leg of the gluteus maximus muscle, quadriceps muscle was maintained at the proximal fragment, the muscle of the broad fascia tensor was not crossed, the periosteum was retained as much as possible. A large trochanter with a proximal femur fragment is rotated in 3 planes and tucked into the window back to front between the muscles, set into the acetabulum, and in this position, while maintaining the orientation parameters of the normal joint, the fragments are fixed with a L-shaped plate. Reposition has been achieved with good adaptation and “suction” - the U-turn was determined by mutually adaptable forms, the position is additionally fixed with knitting needles transcutaneously. In order not to increase the invasiveness of the intervention, at this repositional stage, taking into account the age of the child, pelvic osteotomy was not performed. The operation is completed by applying a hip bandage. After 6 months, when the metalwork was removed, the supramaxillary osteotomy-osteotomy-acetabuloplasty of the pelvis was performed, pelvic fragments after osteotomy were fixed using a bone graft from the iliac crest on the muscle leg. A good centering of the greater trochanter in the acetabulum was achieved, the amplitude of abduction in the joint was up to 50 degrees, rotational movements with an amplitude of 35 degrees. He began to walk with compensation of a shortening of 1.5 cm 1 year after the operation.

In total, 3 operations were performed according to the proposed method. In all cases, bone fusion was achieved, good centering of the greater trochanter with the apophysis in the cavity, a significant functionally advantageous range of motion in the hip joint and stability of the limb during support.

The positive effect of the application of this method is that it allows to achieve good restoration of the function of the hip joint due to spit arthroplasty with the cartilaginous part of the growing apophysis, consolidation of fragments after osteotomy end-to-side when modeling normal physiological parameters of the cervical-diaphyseal relations of the proximal femur without disturbing it nutrition. An optimal transposition of the periarticular muscles is achieved under sparing conditions providing good trophism. The method can be used in the destruction of the neck and femoral head as an aseptic process of osteolysis, as well as the consequences of osteomyelitis.

Claims (2)

1. A method for the surgical treatment of pathological dislocation of the thigh with osteolysis of the head and neck by means of spit arthroplasty, characterized in that Smith-Petersen access is performed, while in the front of the access, the acetabulum is exempted from scars to expose the cartilaginous surface, in the back of the access behind the wide fascia the hips are longitudinally dissected and peeled along with the periosteum of the muscle from the apex of the greater trochanter, spherically model the cartilaginous part of its apophysis, cross the thigh in the undervert region at a distance, the main arm of the neck and head of the healthy side, maintaining the connection of the proximal fragment with the muscles, create a window under the middle gluteus muscle and tensioner of the broad fascia of the thigh and through this hole reposition the large trochanter into the acetabulum, rotate the proximal fragment in three planes for better adaptation until it reaches the centering of the apex of the greater trochanter in the acetabular fossa, placing the small trochanter downward and decorticating the portion of the small trochanter with the lower part of the proximal femur fragment, osteosynthesis of the fragments is carried out with the L-shaped plate end to side at an angle equal to the individual or age norm of the cervical-diaphyseal angle, while the muscles mobilized together with the periosteum are moved to the end part of the bone sawdust and the tensioner of the broad fascia of the thigh is sutured. 2. The method according to claim 1, characterized in that in the case of a reduced acetabulum, an supraclavicular osteotomy of the pelvis is performed with bone grafting simultaneously or in two stages.