RU2240067C1 - Method for endoprosthetics of hip joint - Google Patents

Abstract

FIELD: medicine, traumatology, orthopedics.

SUBSTANCE: one should remove broken fixing plate and proximal femoral fragment at the level of false joint of intertrochanterial area developed after correcting osteotomy, implant femoral component of endoprosthesis upon osseous cement to intraoperationally restore there a greater trochanter with osseous cement to fix gluteal muscles, joint's capsule and a tensor of broad femoral fascia to it. That provides optimal conditions for limb's functioning.

EFFECT: higher efficiency of endoprosthetics.

1 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in hip arthroplasty.

Various types of intertrochanteric osteotomies of the femur remain currently the practically main effective method of surgical treatment of various etiologies of the initial stages of degenerative-dystrophic lesions of the hip joint. This relatively safe and atraumatic operation has become even more attractive for surgeons thanks to the advent of modern immersion fixators (Trotsenko-Nuzhdin, Demyanov, KharNIIITO), which make it possible to exclude the use of external immobilization with an orthopedic splint or plaster coxite dressing. The early functional development of movements in the joints of the operated limb favorably affects the long-term result of surgical intervention.

However, when studying long-term results, the shortcomings of this method of surgical intervention also began to appear. One of them is delayed consolidation and the formation of a pseudoarthrosis in the area of intertrochanteric osteotomy and, according to some authors, make up from 10.4% to 15% (Guryev V.N., 1984: Kornilov N.V. et al., 1997). This complication is especially common in patients of older age groups against the background of local or systemic osteoporosis. In this condition, fractures of retainers that do not withstand excessive loads are also frequent. Repeated operations preserving the proximal femur, as a rule, fail (fusion of the osteotomy and pseudoarthrosis does not occur, and the pathological process of the hip joint itself goes into a more severe stage). The only method for eliminating these phenomena is total hip replacement.

However, all of the above adverse factors create significant technical problems during the endoprosthetics operation, which worsen the result of the endoprosthetics operation.

1. After resection of the femoral head, the remaining fragment of the intertrochanteric region needs to be intramedially fixed with the femoral component of the endoprosthesis, which is technically difficult, and the result is unfavorable due to insufficiently rigid stability. Perhaps a rotational displacement of the femoral component.

2. With pronounced phenomena of osteoporosis, there is almost always a further increase in the phenomena of osteoporosis of the intertrochanteric region of the proximal femur, to which the muscles that provide function in the hip joint are fixed.

3. The installation of the femoral component of the endoprosthesis on bone cement is difficult due to the short part of the intertrochanteric region and difficulties in introducing bone cement into the bone marrow canal.

A known method of hip joint replacement according to the method of K. M. Sivash with temporary cutting off of the greater trochanter and its subsequent fixation with a dowel to the femoral component of the endoprosthesis (Guryev V.N., Coxarthrosis and its surgical treatment, Tallinn, ed. “Valgus”, 1984, p. .254-255) and the technique of hip arthroplasty without cutting off the greater trochanter (Kornilov I.V. et al., St. Petersburg, 1997, p. 183). However, the first method is not applicable when using modern designs of hip arthroplasty, which do not imply such fixation. If the fixation of the greater trochanter is made with wire thread, then in conditions of osteoporosis such osteosynthesis will not be effective. In the second technique, it is very difficult to fix an intramedularly short fragment of the intertrochanteric region with the femoral component of the endoprosthesis. And cement fixation of the femoral component of the endoprosthesis is difficult due to technical difficulties in introducing bone cement into the bone marrow canal of a short fragment of the intertrochanteric region and the femur at the same time.

Closest to the claimed solution, it is also a prototype, is a method of individual endoprosthetics of joints and joint ends according to A.V. Vorontsov (IY All-Russian Congress of Orthopedic Traumatologists, Kuibyshev, 1984, p.186). The essence of the method is intraoperative reconstruction from polymethylmethacrylate (bone cement) using casts of the bone department according to the sample removed. However, using a cast of a large trochanter of the femur and fixing it to the femoral component is difficult enough, which significantly increases the time and invasiveness of the operation.

The purpose of the proposed method is to improve the results of hip arthroplasty.

The objective of the proposed method is to create conditions for the most effective installation of the femoral component of the hip joint prosthesis with pronounced osteoporosis of the proximal femur against the background of the false joint of the intertrochanteric region formed after corrective osteotomy with or without a fracture of the fixation plate.

The essence of the proposed method: produce the removal of the proximal fragment of the femur with the femoral head at the level of the false joint of the intertrochanteric region formed after corrective osteotomy. Then the femoral component of the endoprosthesis is implanted on bone cement. On the femoral component, a large trochanter is reconstructed intraoperatively with bone cement, to which the gluteal muscles, joint capsule and tensor of the wide fascia of the thigh are fixed.

The proposed method of hip arthroplasty is as follows.

An old postoperative scar is excised on the skin. Externally lateral access is performed to isolate the proximal femur. Remove the retaining metal plate (whole or broken). The area of the false joint of the intertrochanteric region is distinguished. The capsule of the joint is opened, the femoral head is dislocated into the wound. The proximal femur fragment is removed together with the head in a single block. If there was also a false joint of the femoral neck, then removal is done in parts (intertrochanteric region, then the head and neck of the femur). The wound is washed with antiseptics, hemostasis is performed. The acetabular component is implanted in a standard way (cement or cementless fixation according to indications). Then, it is necessary to install the femoral component of the endoprosthesis of the required size on bone cement (to prevent rotational mobility).

On the implanted femoral component of the endoprosthesis, a “large trochanter” similar to the removed one is created with bone cement using manual sculpting. In the recreated “large trochanter” along its outer surface with an electric drill with a θ 3.5 mm drill, 4-5 holes are made through which gluteus muscles, a capsule of the joint and a tensor of the broad fascia of the thigh are fixed with lavsan threads sequentially when the surgical wound is sutured. This is a prerequisite for the further beneficial functioning of the lower limb as a whole.

A postoperative wound is drained and sutured according to the classical technique.

Clinical example.

Patient Vysotskaya G.S., 68 years old, East. b. No. 8662/03, was undergoing treatment in the orthopedic department of the Krasnodar Regional Clinical Hospital No. 1 (Krasnodar). Diagnosis: Right-sided idiopathic coxarthrosis of the 2nd stage, condition after intertrochanteric osteotomy, pseudoarthrosis in the osteotomy zone, Trotsenko-Nuzhdin plate fracture.

From the anamnesis: in February 1998, an operation was performed: intertrochanteric variational-medializing osteotomy of the right thigh, fixation with a Trotsenko-Nuzhdin plate. A patient undergoing delayed consolidation in the osteotomy zone in August of the same year underwent rheosthesis with a Trotsenko-Nuzhdin plate, autoplasty with a free bone graft from the iliac crest of a non-growing osteotomy.

In March 2003, she suddenly felt a sharp pain in the hip joint. On radiographs - a fracture of the plate Trotsenko-Nuzhdin, a false joint in the area of intertrochanteric osteotomy (figa).

04/11/2003, the operation in the orthopedic department of the regional hospital No. 1 (Krasnodar) - removal of the metal structure together with the proximal fragment of the femur at the level of the false joint of the intertrochanteric region (Fig. 1b), total endoprosthetics of the right hip joint with the reconstruction of the greater trochanter and cement fixation femoral component (pigv). The postoperative period was uneventful. The surgical wound healed by first intention. The patient began to walk on crutches for 12 days. Examined after a month - full load on the operated limb is allowed. The range of motion recovered to 70% of the norm. On radiographs - the relative position of the components of the endoprosthesis is correct.

The drawing illustrates the removal of the metal structure together with the proximal fragment of the femur at the level of the false joint of the intertrochanteric region, total endoprosthetics of the right hip joint with the reconstruction of the greater trochanter and cement fixation of the femoral component:

a) deforming coxarthrosis on the right 3 stages, the state after intertrochanteric osteotomy, the false joint of the femur at the level of osteotomy with a fracture of the metal structure,

b) the removed proximal fragment of the femur at the level of the false joint of the intertrochanteric region and the broken Trotsenko-Nuzhdin plate,

c) after total arthroplasty of the right hip joint with the reconstruction of the greater trochanter and cement fixation of the femoral component of the endoprosthesis.

Claims (1)

The method of hip joint replacement, characterized in that in the false joints of the intertrochanteric region formed after corrective osteotomy with or without a fracture of the fixation plate and pronounced osteoporosis of the proximal part with the femoral head, the fixation plate and the proximal femur fragment between the femoral joint are removed areas, the femoral component of the endoprosthesis is implanted and a “large trochanter” of bone cement is recreated on it with subsequent fixation glia to it of the gluteal muscles, joint capsule and tensor of the broad fascia of the thigh.