RU2248764C2 - Method for treating fractures of femoral proximal department at detachment of caput femoris lesser trochanter in case of coxarthrosis - Google Patents

Abstract

FIELD: medicine, orthopedics.

SUBSTANCE: one should conduct reposition of fragments on orthopedic table by performing valgusation of femoral proximal fragment. Then one should apply the apparatus of external fixation: one of its rods should be introduced directly into detached lesser trochanter. Then, 7-14 later, one should start to replace it by dosages in time directly into ischial bone. The method enables to create anatomically profitable valgus position of caput femoris followed by fixation of trochanterian fragments, carry out caput femoris unloading and provide earlier activation in patients of older age group.

EFFECT: higher efficiency of treatment.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used for surgical treatment of comminuted periarticular fractures of the proximal femur in the presence of deforming arthrosis of the hip joint.

A known method of surgical treatment of deforming arthrosis of the hip joint (a.s. No. 1777846, A 61 17/56, 11/20/89, published in BI No. 44 for 1992, 11/30/92), including intertrochanteric osteotomy, intraoperative medialization of the distal femoral fragment until the small trochanteric abutment stops in the sciatic bone and subsequent transosseous fixation of the fragments, while the femoral head is unloaded due to the creation of an additional support point, if the medialization towards the pelvis is insufficient and / or excessive, the optimal position of the fragments reaches it further relative displacement of the distal or peripheral femur, manipulating external fixation device.

The disadvantages of this method of treatment are

- the invasiveness of surgical intervention associated with a large surface area of the surgical wound, the possibility of the formation of postoperative hematomas with their subsequent suppuration;

- the clinical effect is insufficient, the rehabilitation period is long.

The closest in purpose and combination of essential features is a method of treating fractures of the proximal femur (a.s. No. 2162304, A 61 B 17/56, 11/20/89, publ. In BI No. 44 for 1992, 11/30/92), including holding a closed reposition on the orthopedic table of fragments, applying a rod apparatus with fixation of the proximal and distal parts of the thigh with rods, in which one compression rod with a persistent thread is inserted into the proximal fragment of the femur through the fracture line, respectively, of the cervical-diaphyseal angle from the subrochanteric region of the thigh in the intramuscular space into the neck and head of the femur, fix the rod to the apparatus and compress the fragments, and the proximal stabilizing rod is carried out through a large trochanter based on the Adams arc.

The disadvantages of this method of treatment are

- the inability to use it for the treatment of comminuted periarticular fractures of the femur in combination with deforming arthrosis,

- the lack of creating an additional fulcrum for unloading the femoral head (output of the small trochanter under the ischium),

- the need for additional surgical intervention in the presence of coxarthrosis of the bone.

The tasks solved by the invention:

- creation of an anatomically favorable valgus location of the femoral head with subsequent fixation of fragments of trochanteric fractures in the presence of a separation of the small trochanter and deforming arthrosis of the hip joint;

- carrying out unloading of the femoral head by creating an additional fulcrum due to the movement of the small trochanter to the ischium;

- ensuring early activation of patients of the older age group.

In the proposed method for the treatment of fractures of the proximal femur in the presence of detachment of the lesser trochanter and deforming arthrosis (coxarthrosis) of the hip joint on the orthopedic table, a closed reposition of the fragments is performed and the rod apparatus is applied to obtain stable fixation of the proximal and distal divisions by introducing rods into the intermuscular spaces through the cortical layers , during reposition, valgization of the proximal femur fragment is performed to unload the lesion of this part of the head, a compression rod with a persistent thread is inserted through the line of fracture, respectively, of the cervical-diaphyseal angle from the undertrochanteric region of the femur into the neck and head of the femur and then the awl-rod is inserted into the torn small trochanter until it stops, starting from 7-14 days after the operation, further discrete time-controlled displacement of the small trochanter to the stop in the ischium, thereby creating a mechanism for controlling in time the relative position of the fragments of the femur, and valgization I and the creation of an additional fulcrum form a new anatomically and biomechanically beneficial structure of the hip joint.

The proposed method of treatment differs from the prototype by conducting, during a closed reposition, additional valgization of the proximal fragment, introducing the rod-awl of the rod apparatus in the direction and with emphasis in the small trochanter and the implementation of the further time-controlled traction of the small trochanter to the pelvis until it stops in the ischial bone, resulting in an additional fulcrum.

The proposed method of treatment allows you to go to a new level and quality of treatment for patients with comminuted extraarticular fractures of the proximal femur in the presence of deforming arthrosis by combining the previously performed two operations (surgical correction of femoral fractures and surgical treatment of deforming arthrosis with pain) and the creation of a new low-traumatic a method of obtaining the valgus position of the proximal femur, the use of a torn small trochanter for ra loading the affected part of the head and its further discrete and controlled displacement into the ischium with the formation of optimal biomechanics of the hip joint.

Fractures of the trochanteric region are characteristic of elderly and senile patients, when, due to involutive (dystrophic) and dishormonal processes in the body, cortical (cortical) and trabecular (spongy) bone structures are thinned to the greatest extent, characteristic of metaphysical (periarticular) localizations. At the same age, degenerative and dystrophic processes in the femoral head most often develop, leading to coxarthrosis and pain, which often requires surgical intervention.

Reducing the length of hospital stay and early activation of patients of the older age group is achieved by optimizing the processes of physiological and reparative regeneration of bone tissue, due primarily to reliable fixation of bone fragments, a saving attitude to osteogenic tissues, low invasiveness of surgical intervention, and the creation of prerequisites for improve blood supply to bone fragments and the femoral head, accelerate metabolic and recovery processes during I traction minor trochanter due to the formation of distraction regenerate.

The invention is illustrated by the following illustrations:

- figure 1 - x-ray positioning of the fragments after surgery;

- figure 2 - x-ray positioning of fragments in the process of traction;

- figure 3 - x-ray of the hip joint with a strong fusion of fragments and the creation of an anatomically favorable position of the fragments.

The method is carried out in the following sequence.

The operation is performed under spinal anesthesia while the patient is standing on his back.

On the orthopedic table, a closed reposition of fragments is carried out by abduction and traction of the limb along the axis and internal rotation. Excessive traction along the limb axis and valgization set the cervical-diaphyseal angle (SCD) within 135-140 °, and then carry out radiological monitoring of the position of the fragments of the femur with radiopaque landmarks.

Next, a rod apparatus is applied and the proximal and distal parts of the thigh are fixed with rods: focusing on the cervical-diaphyseal angle from the underrovert region through a puncture of the skin in the intermuscular zone, a channel is formed in the neck and head of the femur into which a compression rod with a persistent thread is inserted. Then enter the awl rod with the direction and with emphasis in the cortical layer of the lesser trochanter. In the distal femur below the fracture line along the outer surface of the thigh after puncture of the soft tissues, more channels are formed into which distal stabilizing rods are inserted. All rods are fixed to the base support of the rod apparatus. This position is illustrated in Figure 1.

In the postoperative period, after 1-2 weeks, the small trochanter begins to shift to the ischium with the awl-rod by 1 mm per day, 0.25 mm four times a day. This position is illustrated in Figure 2. The total amount of displacement is controlled according to x-ray examination: until the emphasis of the small trochanter is established in the sciatic bone. After which the displacement is completed. This position is illustrated in Fig.3. The period of fixation by the pivotal apparatus lasts until the fragments are fused and a new bone appears in the diastasis of the lesser trochanter, the femur.

Example. Patient G. at the age of 71 was in SarNIIITO for a closed transversal fracture of the left femur with a separation of the small trochanter. Concomitant disease: coxarthrosis on the left 1-2 degrees with pain.

The patient underwent surgery according to the proposed method. After a closed reposition of fragments on the orthopedic table with valgization of the proximal fragment, X-ray inspection of the fragments was performed, which recorded a cervical-diaphyseal angle of 138 °. Then, the subrochanteric region of the femur after puncture of soft tissues in the intermuscular space, a channel was formed coaxially with the axis of the neck and the femoral head, into which a compression rod with a persistent thread was introduced. The next rod, the awl rod, was introduced in the direction and with emphasis on the small skewer. In the distal femur, distal stabilizing rods were inserted through both cortical layers. All rods are fixed to the base support of the apparatus.

After surgery, the patient is activated: within the hospital bed (taught herself to sit down and stand up) - for 3-4 days; learned to walk relying on crutches, metered loading the operated limb - for 6 days. After 1.5 weeks (10 days), traction of the lesser trochanter to the ischium began. According to x-ray control, the emphasis of the lesser trochanter in the sciatic bone was noted on day 13. Further displacement (traction) was stopped. The rod apparatus is stabilized. The patient was discharged home from the hospital on the 23rd day. The fracture healed after 3.5 months, after which the device was dismantled. When monitoring the long-term result, after 12 months, the function of the hip joint was fully restored, and there was no pain in the hip joint before the injury.

Medical and social effectiveness of the method is:

- in creating a stable anatomically beneficial fixation of trochanteric fractures with separation of the minor trochanter and deforming arthrosis;

- in the simultaneous treatment of coxarthrosis and healing of the fracture;

- in stimulating blood supply and regenerative processes of bone tissue in the area of a fracture and a degeneratively altered femoral head;

- in the early restoration of joint function of a sick limb;

- in the early activation of patients of the older age group;

- in relieving patients from pain.

Claims (1)

A method for the treatment of proximal femur fractures with detachment of the small trochanter during coxarthrosis of the hip joint, comprising conducting a closed reposition on the orthopedic fracture table, applying an external fixation rod apparatus, characterized in that during reposition the proximal femur fragment is valgated, one of the apparatus rods is introduced until it stops in a torn small trochanter, after 7-14 days they begin to move it in a dosage manner in time until it stops in the ischial bone.

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