RU2338475C2 - Treatment method of deformation of hip proximal department - Google Patents

Abstract

FIELD: medicine; traumatology.

SUBSTANCE: carry out an osteotomy from a trochanterian fossa in a direction from top to down from inside to the outside with formation of the osteal fragment including the greater trochanter. Perform the dosed out transposition of the osteal fragment including the greater trochanter, downwards and to the outside. Fix femur fragments using the perosseous device before obtaining osteal regenerate.

EFFECT: provision of unloading of a joint and reduction of deformation relapse risk.

2 cl, 1 ex, 8 dwg

Description

The invention relates to medicine, in particular orthopedics, and is used in the treatment of varus deformity of the femoral neck of various etiologies, combined with major trochanteric hyperplasia, using transosseous fixation.

There is a method of distal displacement of a large trochanter, during which an external longitudinal incision is made of the skin and soft tissues in the upper third of the thigh at least 10 cm, the proximal femur is subperiostally separated, an osteotomy is performed from the lower external edge of the trochanter in the direction of the trochanteric fossa, and the osteotomized trochanter is mobilized from the joint capsule and the surrounding soft tissues, move the skewer down and out onto the previously prepared lateral surface of the femur, t its fixation to the femur using thick Kirschner spokes or threaded rods (Tachdjian, M.O. Distal and lateral advancement of the greater trochanter. // New York, 1982. - P.723-730).

However, the known method is technically complicated, causing significant damage to the soft tissues surrounding the joint. The simultaneous transposition of the greater trochanter with subsequent fixation with knitting needles or rods excludes the possibility of additional correction of its position in the postoperative period. The use of rods can cause fragmentation of the osteotomized trochanter. The use of knitting needles does not provide sufficient fixation for the spit, which increases the risk of forming a false joint.

The present invention is to develop a method that allows you to restore the correct ratio between the top of the greater trochanter and the femoral head by means of less traumatic transposition and subsequent stable fixation of the greater trochanter.

The problem is solved in that in a method for treating deformation of the proximal femur, including violation of the integrity of the femur, by osteotomy and transposition of the trochanteric bone, fixation of bone fragments, perform osteotomy from the trochanteric fossa from top to bottom from the inside out with the formation of a bone fragment comprising a large trochanter , carry out its fixation with knitting needles, make a metered transposition of the bone fragment, including the greater trochanter, down and out, after which the bone fragments are the sodal bone is fixed by transosseous device until bone regenerate is obtained.

It is advisable in the presence of decentralization of the femoral head due to dysplasia of the acetabulum additionally produce an osteotomy of the pelvic bones and the inclination of the acetabulum.

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

Figure 1 - diagram of the osteotomy of the trochanteric region and fixation of osteotomized fragments transosseous device during transposition of the greater trochanter;

Figure 2 is a diagram of the position of osteotomized fragments of the femur and their fixation after the end of transposition of the greater trochanter;

Figure 3 - diagram of the fixation of bone fragments transosseous device;

Figure 4 is a copy of the x-ray of the patient before treatment;

5 is a copy of the x-ray of the patient in the process of distraction;

6 is a copy of the x-ray of the patient after fixing a large trochanter transosseous device;

7 is a copy of the x-ray of the patient 10 months after treatment;

Fig. 8 is a photograph of a patient 10 months after treatment.

The method is as follows.

At least four knitting needles are passed through the iliac wing, they are fixed in the arc support of the transosseous device with the help of knuckles and pulled (Figure 1). 3-4 spokes are passed through the distal metaphysis of the femur, fix them in ¾ rings with the help of spokes and tighten. At the border of the upper third and middle third of the thigh, two spokes intersecting at an angle of 30-35 ° are held with thrust pads towards each other. The spokes are fixed to the arc and pulled. The arc is connected to a support on the distal metaphysis of the thigh using rods. The thigh is set in an extension position of 180 ° and internal rotation, corresponding to the value of the anteversion of the proximal femur. If the patient has neck retroversion, the thigh is set to the external rotation position corresponding to the value of retroversion. The arch support, located on the border of the upper and middle third of the thigh, is connected by rods with an arch mounted on the ilium.

Two spokes are drawn through the trochanteric region. The first spoke is introduced in the direction from the bottom up at an angle of 30-40 ° to the surface of the body. On the back surface of the femur, a thrust pad is formed on the spoke. A threaded rod with a groove is installed on the end of the spokes on the front surface. The other end of the spoke remains free. The second spoke is carried out from top to bottom at an angle of 40-50 ° to the surface of the body. A thrust pad is formed on the spoke, which is immersed under the skin all the way into the front surface of the thigh. A threaded rod with a groove is installed on the rear end of the spoke, the front one is left free.

On the front surface of the hip joint set spokes labels (not shown). Their location corresponds to the level and direction of the proposed osteotomy, which is determined during the preoperative design.

The location of the spokes of the marks is specified using X-ray of the hip joint in the anteroposterior projection. On the front surface in the upper third of the thigh, inward from the spokes introduced into the trochanteric region, a 4-5 cm skin incision is made, soft tissues are stupidly stratified. A narrow chisel from the trochanteric fossa to the outer edge of the femur produces an osteotomy, the direction of which corresponds to the spoke mark. The mobility of the osteotomized trochanter is checked by displacing it in the distal direction. Then the ends of the spokes with threaded rods mounted on them are fixed to the arc support on the thigh using cantilever consoles. Suture the wound. In the presence of torsion deformation of the proximal femur, the tactics of treatment are determined by its value. If the necessary correction of the pathological deviation of the femoral neck does not exceed 20 °, it is carried out by moving the large trochanter anteriorly. To do this, after mobilization of the trochanter, the rods installed between the pelvic and femoral supports are relaxed, and, holding the trochanter in its original position, rotate the hip outward. After that, spokes with thrust pads drawn through the trochanteric region are also fixed to the arc support on the thigh. Then they connect the pelvic and femoral supports with rods. Suture the wound. With a more pronounced torsion deformation, it is eliminated with the help of additional corrective osteotomy.

In the postoperative period, a gradual transposition of the trochanter is carried out by distraction along the rods, each of which is installed in cantilever consoles. After the movement of the greater trochanter in the operating room is completed, a spoke is drawn through the displaced bone fragment, it is bent in an arcuate manner, fixed to the arc support on the thigh, and tensioned (Figure 2). From the side of the greater trochanter in the direction from top to bottom, from the inside to the inner cortical plate of the thigh, 5-6 diafixing spokes are carried out, the free ends of which are fixed with spokes on a cantilever attachment mounted on an arc femoral support (Figure 3). Remove the spokes with thrust pads previously drawn through a large skewer. 2.5-3 months after the consolidation of bone fragments in the area of the osteotomy of the femur, the apparatus is removed, the spokes are removed and the development of movements in the hip joint begins.

An example of the method.

Patient 16 years old, medical record inpatient No. 49690. Diagnosis:

Left-sided dysplastic coxarthrosis, left hip subluxation, contracture of the left hip joint, shortening of the left lower limb 2 cm. Complaints about lameness, increased fatigue, pain in the hip joint after exercise. According to X-ray data: decentralization of the head of the left thigh, acetabulum flattened, Sharpe angle 33 °, degree of coverage of the head of the roof of the hollow 50%, Viberg angle negative, varus deformation of the neck of the left thigh 100 °, anteversion angle 20 °, the top of the greater trochanter is at the level of the reference the surface of the head (ATD = 0 mm), the femoral neck is shortened (Figure 4).

The patient underwent surgery. In the operating room, under intravenous anesthesia, 6 spokes were held through the iliac wing, which were fixed in an arc and stretched. Through the distal metaphysis of the femur, 4 spokes are held, which are fixed in 3/4 rings and stretched. At the border of the upper third and middle third of the thigh, two intersecting spokes with thrust pads were made, fixed in an arc, which is connected to the support on the distal metaphysis of the thigh using rods. Since the patient had decentralization of the femoral head due to dysplasia of the acetabulum, the first stage was performed osteotomy of the pelvis and reorientation of the acetabulum. After 48 days, the patient was re-taken to the operating room. The thigh is set in an extension position of 180 ° and an internal rotation of 20 °. A needle is drawn through the trochanteric region in the direction from the bottom up at an angle of 30-40 ° to the body surface. A persistent platform is formed along the posterior surface of the femur. A threaded rod with a groove is installed on the front end of the spoke. The second spoke is held in a downward direction at an angle of 40-50 ° to the surface of the body. Formed persistent platform on the front surface of the femur. A threaded rod with a groove is installed on the rear end of the spoke. Label spokes were installed, control radiography was performed. A 6 cm skin incision was made along the front surface of the thigh, soft tissues were stupidly stratified. From the trochanteric fossa to the outer edge of the greater trochanter, an osteotomy of the femur was performed.

The threaded rods mounted on the ends of the spokes inserted into the skewer, using cantilever consoles, are fixed to the arc support on the thigh (Figure 5). Stitched to the wound. From the sixth day for 11 days, by means of distraction along the rods, the spokes were tensioned with thrust pads inserted into the skewer. After the end of distraction in the operating room under anesthesia, a spokes were drawn through a displaced bone fragment, including a large trochanter, a curved arc, fixed to an arch support on the thigh, and stretched. From the side of the greater trochanter in the direction from top to bottom, from the inside to the inner cortical plate of the thigh, 5 diafixing spokes were made, the free ends of which are fixed with spokes on a cantilever attachment mounted on an arc femoral support (Figure 6). Spokes with thrust pads previously drawn through a bone fragment including a large trochanter are removed. The duration of fixation of fragments of the femur in a corrected state is 92 days. After dismantling the device and removing the spokes, a course of rehabilitation treatment was carried out.

10 months after removal of the device, the patient walks with a full load on the left leg. The symptom of Trendelenburg is negative. The relative length of the lower extremities is the same. The range of motion in the right hip joint was fully restored (Fig. 8). According to x-ray data: the head of the left thigh is spherical in shape, centered in the cavity, the degree of coverage of the roof of the cavity is 100%, the Vieberg angle is 35 °, and the ShDU is 110 °. The top of the greater trochanter at the level of the center of the femoral head, the distance from the top of the greater trochanter to the supporting surface of the head (ATD) is 22 mm. Lateralization of the top of the greater trochanter (LT) 53 mm (Fig. 7). The result of the treatment is regarded as good.

The application of the proposed method allows you to restore the broken relationship between the femoral head and the greater trochanter, which helps to improve the functioning conditions of the gluteal muscles due to the increased distance between the points of their attachment. Its advantage is the ability to correct the position of the osteotomized fragment in the postoperative period. The gradual transposition of the spit with the formation of a distraction regenerate reduces the risk of pseudoarthrosis even when using spoke fixation. Less traumatic intervention is achieved by performing a small incision with the preservation of the muscles and soft tissues surrounding the greater trochanter.

The proposed method eliminates the compression of the hip joint due to the tension of the gluteal muscles, ensures its sufficient unloading, which prevents the progression of degenerative changes in the articulation elements.

The use of an external fixation device makes it possible to activate the patient from the first days after surgery and facilitates the care of him during treatment.

The proposed method is used in the orthopedic department No. 9 of the Federal State Institution Scientific and Research Center “WTO” named after Academician G.A. Ilizarov in the treatment of children over 8 years old with deformation of the proximal femur, accompanied by hyperplasia of the greater trochanter.

Claims (2)

1. A method of treating proximal femoral deformity, including violation of the integrity of the femur by osteotomy and transposition of the greater trochanter, fixing bone fragments, characterized in that an osteotomy is performed from the trochanteric fossa from top to bottom from the inside outwards with the formation of a bone fragment including a large trochanter, its fixation with needles, a metered transposition of the bone fragment, including the greater trochanter, is made down and out, after which the bone fragments of the femur are fixed iruyut transosseus device to obtain callus. 2. The method according to claim 1, characterized in that it additionally produce an osteotomy of the pelvic bones and the inclination of the acetabulum.

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