RU2322204C1 - Method for recreating cotyloid cavity in hip joint dysplasia cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out complete iliac bone body intersection, using transosseous device fro fixing bone segments and dosed bone fragments traction. Dosed pelvic bone distal fragment inclination is carried out outwards and downwards to restore regular spatial cotyloid cavity orientation in frontal plane. The bone fragments are fixed in achieved position. Periacetabular osteotomy is done with slivers being produced in anteroexternal segment of cotyloid cavity roof. It is fixed with wires and dosed displacement outside and forwards is performed with rigid distraction regenerate being produced to form cotyloid cavity matching femur head in shape and volume. Bone fragments are kept fixed until bone regenerate is produced.

EFFECT: enhanced effectiveness in recovering regular spatial configuration, shape and volume of cotyloid cavity.

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Description

The invention relates to medicine, namely to orthopedics, and is used in the treatment of school-age children with hip dysplasia, accompanied by a pronounced flattening of the acetabulum, using transosseous fixation.

There is a method of reconstruction of the hip joint, in which a periacetabular osteotomy is performed, followed by the incline of the acetabulum for the femoral head, then the entire body of the ilium is completely crossed and the distal pelvic fragment is rotated in the pubic joint, a bone wedge is inserted between the pelvic fragments and the bone wedge is fixed. fragments with knitting needles, impose a hip plaster cast (A.S. 1144696, USSR, publ. March 15, 1985, bull. 10).

However, the simultaneous implementation of periacetabular osteotomy and osteotomy of the ilium body without the use of a transosseous device is technically difficult, since it is difficult to control the position of the bone fragments during the operation. The need for wide access, double intersection of the ilium increases the invasiveness of the intervention. With the simultaneous execution of two osteotomy near the acetabulum, the risk of developing necrosis of the acetabular fragment increases. The simultaneous reconstruction of the acetabulum, followed by fixation with a graft and knitting needles, eliminates the possibility of additional correction in the postoperative period.

There is a method of treating hip dislocation, in which an incomplete periacetabular osteotomy of the ilium is performed to the level of a V-shaped cartilage, followed by its gradual tilt using a distraction apparatus (Malakhov O.A. Distraction method of acetabuloplasty for congenital dislocation of the hip. Diseases and damage to large joints in children) . - L .: 1989, p. 58-61).

However, the application of the known method with a pronounced flattening of the acetabulum contributes to the formation of angular deformation of its arch, which increases the discongruence of the articular surfaces and causes the progression of degenerative-dystrophic changes in the joint.

There is a method of treating hip dislocation, in which a complete intersection of the ilium body in a horizontal plane is performed, the distal part of the pelvic bone is fixed with needles, it is metered outward, downward and anteriorly by means of a transosseous device, after which bone fragments are fixed until a bone regenerate is obtained (Pat No. 2232558 of the Russian Federation, publ. July 20, 2004 Bull. No. 20).

However, with a pronounced flattening of the acetabulum and a mismatch of the size of the head diameter in school-age patients, when the ability of the cavity to remodeling is reduced, the inclination of the distal pelvic bone using the transosseous device does not provide sufficient joint stability in the horizontal plane and does not exclude lateral position of the femoral head.

The objective of the present invention is to restore the correct spatial position, shape and volume of the acetabulum in accordance with the size of the femoral head in patients of school age with a significant flattening of the cavity and deskongruentnost joint components.

The problem is solved in that in the method of reconstruction of the acetabulum with hip dysplasia, including the complete intersection of the ilium, the use of a transosseous device for fixing bone segments and a dosed traction of bone fragments, the metered tilt of the distal fragment of the pelvic bone outward and down to restore the correct spatial orientation of the acetabulum in the frontal plane, while the bone fragments are fixed with needles in the floor reached After performing this procedure, a periacetabular osteotomy is performed with a flake in the anterolateral part of the acetabulum roof, then it is fixed with needles and dosed outward and anteriorly with the formation of a rigid distraction regenerate until the formation of the acetabulum, corresponding in shape and volume to the femoral head, after which the bone fragments are fixed until receiving bone regenerate.

The invention is illustrated by a description, a specific example of its implementation, diagram and attached copies of x-rays, on which:

figure 1 - diagram of the method;

figure 2 is a copy of the x-ray of the patient before treatment;

figure 3 is a copy of the x-ray of the patient after complete intersection of the ilium;

4 is a copy of the x-ray of the patient during the dosed tilt of the distal fragment of the pelvic bone outward and downward;

5 is a copy of the x-ray of the patient after performing periacetabular osteotomy;

6 is a copy of the x-ray of the patient three years after treatment.

The method is as follows.

In an operating room under anesthesia, two knitting needles with thrust pads are inserted through the middle third of the thigh; four knitting needles are passed through the distal metaphysis of the thigh. A transosseous device of two supports is mounted, the spokes are pulled. The supports are connected with threaded rods. Through the wing of the ilium, 4-5 spokes with thrust pads are held, which are fixed and pulled in the arch of the transosseous device (Fig. 1). Reliance on the distal metaphysis of the thigh is not shown. Closed centering of the femoral head in the acetabulum is performed. The hip joint is fixed in the position of abduction and full extension of the limb using rods with articulated devices that are installed between the supports on the pelvic bone and in the middle third of the thigh. The amount of abduction corresponds to the difference between the angle of vertical deviation of the depression in the patient and the normal rate (45 °). Distraction is performed on the rods installed between the pelvic and femoral supports, 1-2 mm to unload the hip joint, then through the trochanteric region, the neck of the femur, the supraverticular region from the bottom up, from outside the transarticular 2-3 needles are carried out, which are immersed in the pelvic bone to a depth of 1.5-2.0 cm. The free ends of the spokes are fixed to the support on the thigh. Through a transverse incision 3-4 cm long under the anteroposterior spine, transverse osteotomy of the ilium is performed. Through the distal fragment of the pelvic bone in the direction from top to bottom from inside to outside from front to back, two spokes with thrust pads are carried out, which bend arcuately and fix to the support on the thigh. Suture the wound. 4-5 days after surgery, distraction begins on the outer shaft between the pelvic and femoral supports 1.5-2 mm per day for tilting the distal fragment of the pelvic bone down and out, which allows for a gradual reorientation of the acetabulum in the frontal plane. After reaching the required angle of vertical deviation of the cavity (45 °), the patient is re-taken to the operating room. Through the distal fragment of the pelvic g at a distance of at least 1.5 cm from the edge of the acetabulum in the frontal plane from the inside to the inner cortical plate, at least two cantilevered spokes are drawn, the free ends of which are fixed to the support on the ilium. Previously performed transarticular and arcuate curved spokes are removed. The rods are installed between the pelvic and femoral supports. The limbs give the position of abduction, flexion and internal rotation, which is fixed using rods with hinged devices. The amount of abduction is determined so that the angle between the axis of the diaphysis of the thigh and the line connecting the center of the femoral head and the outer section of the roof of the cavity is at least 25 °. The value of the angle of internal rotation corresponds to the difference between the angle of anteversion of the patient and the normal indicator of the angle of antversion. The limb flexion angle is determined so that on the axial projection the femoral head is below the horizontal line drawn through the front edge of the cavity.

A 1-2 cm incision is made on the outer surface of the hip joint. Set the chisel on the outer edge of the distal fragment of the pelvic bone below the previously held cantilever spokes. In parallel to the arch of the acetabulum in the direction from the inside of the medulla, from top to bottom to the U-shaped cartilage, a periacetabular osteotomy is performed. 2-3 through spokes with thrust pads are inserted into the formed osseous cleft, which bend arcuately and fix to the support on the femur. Suture the wound. In the presence of valgus-torsion deformity of the proximal femur, corrective osteotomy of the femur is performed.

In the postoperative period, by means of distraction along the anterior and external rods installed between the pelvic and femoral supports, the limb is gradually reduced and extended, as a result of which there is a metered tilt of the osteotomized bone flake anteriorly, outward and downward, accompanied by the formation of a rigid regenerate, which during a gradual reversal the femoral head undergoes transformation, which allows you to restore the necessary shape and volume of the acetabulum. After that, bone fragments are fixed until bone regenerate is obtained.

Patient B., 10 years old, medical history No. 35938

Diagnosis: congenital dislocation of the right thigh, combined contracture of the right hip joint, shortening of the right lower limb 2 cm. Complained of lameness, pain in the hip joint. The patient walked with two crutches. Movement in the right hip joint: 70 ° flexion, 170 ° extension, 110 ° abduction. On the x-ray (figure 2), the marginal dislocation of the right thigh, the Shanton line is broken by 3 cm, the acetabulum is sharply flattened: the thickness index of the bottom of the cavity is 0.85, the acetabular index is 44 °, the angle of vertical deviation of the cavity is 27 °. ШДУ 105 °, anteversion angle 45 °. The ratio of the length of the entrance to the cavity to the diameter of the head is 1.9, the ratio of the length of the arch of the cavity to the diameter of the head is 0.65, which indicates a significant discrepancy between the sizes of the head and the acetabular fossa.

The patient underwent surgery. In the operating room, under intravenous anesthesia, 5 spokes were inserted through the iliac wing, 2 spokes were inserted through the middle third of the femur, and 4 spokes were inserted through the distal metaphysis of the femur. All spokes are fixed in the supports of the transosseous device (such as the Ilizarov apparatus). Produced simultaneous closed centering of the head in the cavity. The thigh is fixed in the abduction position 110 °, extension 180 °. In the achieved position of the operating room under anesthesia through the trochanteric region, the lateral part of the neck of the femur, the supraverticular region of the transarticular and acetabulum in the direction from bottom to top, from the inside, 3 spokes were held, the free ends of which are fixed to the support on the thigh. Through a transverse incision 4 cm long under the anteroposterior spine, a transverse iliac osteotomy was performed. Through the distal fragment of the pelvic bone in the direction from top to bottom from inside to outside from front to back, two spokes with thrust pads, which are curved arcuate and fixed to the support on the thigh, are drawn (Fig. 3). Stitched to the wound. From the fourth day after the operation, distraction was performed over the outer shaft between the pelvic and femoral supports at a rate of 2 mm per day for 15 days. As a result, the angle of vertical deviation of the depression increased to 46 ° (Fig. 4). Two weeks after the end of reorientation of the acetabulum, the patient was re-taken to the operating room. Through the distal fragment of the pelvic bone at a distance of 1.5 cm from the edge of the acetabulum in the frontal plane from the inside to the inner cortical plate, 4 cantilever spokes were made, the free ends of which are fixed to the support on the ilium. Previously performed transarticular and arcuate curved spokes are removed. The rods installed between the pelvic and femoral supports are relaxed. The limbs are given the position of the lead 110 °, bending 150 ° and internal rotation 30 °, which is fixed using rods with hinged devices. A 2 cm incision was made on the outer surface of the hip joint. Below the cantilevered spokes, parallel to the vault of the acetabulum in the direction from the outside, from the inside, from top to bottom, to the U-shaped cartilage, a periacetabular osteotomy was performed. 3 through knitting needles with thrust pads, which are curved arcuate and fixed to the support on the femur, are introduced into the formed bone flap. Stitched to the wound. A transverse osteotomy was performed in the lower third of the thigh. The distal femur fragment is rotated outwardly by 30 °. In the postoperative period, for 20 days, by means of distraction along the front and outer rods installed between the pelvic and femoral supports, the osteotomized bone flakes of the periacetabular region were dosed forward, outward and downward with the formation of a rigid regenerate, the gradual transformation of which allowed to restore the spherical shape of the arch and volume acetabulum (figure 5). The duration of subsequent fixation of bone fragments was 80 days. After removal of the apparatus, rehabilitation measures were launched aimed at restoring the function and debatability of the limb.

At the control examination after three years, the patient walks with a full load, lameness decreased. Movement in the hip joint corresponds to the preoperative level. On the roentgenogram, the head of the right thigh is centered in the cavity: the Shanton line is not broken, the Viberg angle is 35 °, and the LHV is 100%. Acetabulum of spherical shape, acetabular index 10 °, angle of vertical inclination of the depression 52 °. The ratio of the length of the entrance to the cavity to the diameter of the head is 1.4, the ratio of the length of the arch of the cavity to the diameter of the head is 1.2, which indicates the correspondence of the size of the head to the volume of the acetabular fossa (Fig.6).

The application of the proposed method in patients of school age with a pronounced flattening of the acetabulum provides sufficient stability of the hip joint after eliminating the dislocation of the head. The advantage of this method is the ability to control the spatial position of osteotomated bone fragments during treatment. The gradual movement of the flank of the supra-acetabular region with the formation and subsequent transformation of a rigid rigid distraction regenerate ensures the formation of a spherical acetabulum corresponding to the size of the femoral head, which allows to improve the congruence of the articular surfaces.

Reducing the invasiveness of the intervention is achieved by phasing corrective operations on the ilium, using small incisions to prevent significant damage to the muscles and soft tissues surrounding the joint, and refusing to use the graft.

The use of a transosseous device (Ilizarov apparatus) enables early activation of the patient in the postoperative period.

The proposed method is used in the orthopedic department No. 9 of the Federal State Institution Scientific Research Center "WTO" Academician G.A. Ilizarov.

Claims (1)

A method for reconstructing the acetabulum with hip dysplasia, including complete intersection of the ilium body, using a transosseous device for fixing bone segments and dosed traction of bone fragments, characterized in that the distal portion of the pelvic bone is dosed outward and downward until the correct spatial orientation of the acetabulum is restored in the frontal plane, after reaching the angle of deviation of the acetabulum at 45 ° I fix bone fragments with knitting needles in the achieved position, perform periacetabular osteotomy with the formation of a flake in the anteroposterior part of the acetabulum roof, then it is fixed with knitting needles and metered outward and anterior and downward with the formation of a rigid distraction regenerate until the formation of the acetabulum corresponding to the shape and volume of the femoral head, after whereby bone fragments are fixed to obtain bone regenerate.

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