RU2355339C2 - Cotyloid cavity autoosteoplasty technique in inspective hip joint replacement - Google Patents

Abstract

FIELD: medicine; orthopaedics and traumatology.

SUBSTANCE: first stage involves forming a bone fragment of greater pedicle trochanter matched with the defect of cotyloid cavity. A transplant is perforated with a drill and temporarily fixed with two-three sutures to its bed. The second stage is executed 3-4 weeks after the first stage, and includes treating the defect of cotyloid cavity. The prepared autograft is placed in cavity so that to close defect at most. Then it is fixed to hip bones with 2-3 screws. Then cavity is prepared to install cotyloid endoprosthesis component.

EFFECT: method allows preparing cotyloid cavity for replacing cotyloid endoprosthesis component.

4 cl, 1 ex, 2 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics for the treatment of patients with instability of the hip joint prosthesis in the presence of an acetabulum defect.

It is known that at present up to 1,500,000 major joint arthroplasty operations are performed annually in the world. As the number of implanted endoprostheses increases, due to various reasons, the need for their replacement, that is, the operation of revision endoprosthetics, increases. According to various sources, the need for revision arthroplasty is up to 10-15% of the number of initially installed arthroplasty. In fact, an “epidemic” of revision hip arthroplasty is developing. If the initial total hip replacement has become a standard operation, then revision arthroplasty is always an individual complex surgical intervention that requires experience and special training. Difficulties in diagnosis and preoperative planning, work with cicatricial, in some cases infected tissues, violation of normal anatomy, massive tumor-like granulomas, extensive defects in the acetabulum and femur make each such intervention strictly individual and unique in its own way (1, 2, 3).

This is especially true for Russia, since over the past decades, low-quality endoprostheses of domestic production have been implanted, which often led to the rapid development of endoprosthesis instability with significant bone destruction, as well as infectious complications (3, 4).

With endoprosthesis instability, various defects of bone tissue are noted, both of the acetabulum and the femur (1, 4).

The technique of revision arthroplasty is usually different from primary arthroplasty. One of the reasons for this is a significant loss of bone tissue around the primary implant. When fixing the primary endoprosthesis with cement, before installing a new artificial joint, the remains of cement in the femoral canal and acetabular cavity should be removed. Removal of the primary prosthesis, cement often requires the use of special tools, additional incisions, osteotomy, or resection of bone sites. All this is accompanied by additional bone loss. To fix the components of the endoprosthesis and close the formed bone defects, a patient’s own bone is taken, for example, from the pelvic bone, and its replacement in place of the destroyed bone. But this method requires additional incisions, which increases the invasiveness of operations, and established transplants devoid of supply vessels may undergo lysis (1, 3, 4).

The task can also be solved by allo-osteoplasty (demineralized, decalcified, structural and non-structural bone allografts). However, in this case, it is not always possible to achieve functional bone reconstruction of the grafts (2, 4).

There are various artificial (metal) structures that form the acetabulum. But the use of this method is very limited due to the lack of individuality of the structures used, as well as the impossibility of their use in cases of extensive bone defects.

The objective of this study is to develop a method for closing the wall defect of the acetabulum using an autograft from a large trochanter of the femur on the feeding leg for subsequent fastening in the cavity of the acetabular component of the endoprosthesis.

We have proposed a method for auto-osteoplasty of the acetabulum during revision hip arthroplasty, including two stages of intervention. At the first stage, the endoprosthesis is removed, scars and granulations in the acetabulum are removed, the size of the acetabulum defect is determined, an autograft is formed - a bone fragment from a large trochanter on the feeding leg, the autograft is perforated with a drill and fixed with two or three transosseous sutures to its bed, the wound is sutured. At the second stage, 3-4 weeks after the first stage, the acetabulum defect is treated, the sutures with which it was fixed to its bed are removed from the autograft, the autograft is mobilized on the feeding leg, placed in the acetabulum, closing the defect, the autograft is fixed to the bones the pelvis with 2-3 screws, then the acetabular component of the endoprosthesis is installed.

If there are still defects when replacing an acetabulum defect with an autograft from a major trochanter, they are replaced with spongy autografts taken from the iliac crest.

The feeding leg of the autograft from the greater trochanter is formed on the feeding leg from bundles of the gluteus maximus muscle or from bundles of two muscles: the middle and gluteus maximus muscle.

The claimed method is as follows. After removal of the endoprosthesis, scars and pathological granulations and the identification of an acetabulum bottom defect in order to prepare for plastic surgery, a bone fragment is formed from a large trochanter on the feeding leg with the shape and size of the acetabulum defect using a chisel and an oscillatory saw.

The autograft feeding leg in most cases is cut out from bundles of the middle and small gluteal muscles. It is optimal to form a feeding leg from one muscle - the gluteus maximus - since it lies in the deepest layer and allows very convenient to transfer a fragment of the greater trochanter to the acetabulum without tension and excesses. However, the allocation of the gluteus maximus muscle is often very difficult, therefore, usually for the formation of the feeding legs use bundles of two muscles - the small and medium gluteal. Accordingly, nutrition is carried out due to the branches of the first order of the superior gluteal artery.

Then the transplant is perforated with a thin drill and temporarily fixed with two or three sutures to its bed (figure 1). To adapt the regenerate to new conditions of blood supply, the wound is sutured for 3-4 weeks.

At the second stage, after processing the acetabulum defect, the prepared autograft is moved to the feeding leg and placed in the cavity so as to close the defect as much as possible, and the autograft is fixed with 2-3 screws (Fig. 2). Further, the cavity is processed to install the acetabular component of the endoprosthesis, and in some cases there is a need to use anti-protrusion rings (Mueller, Hans, Burs-Schneider, etc.).

According to the claimed method, 4 patients were operated on. The follow-up period after surgery ranged from 1 to 4 years. All patients received a good result - the desired functional restructuring of osteografts was noted, the acetabular components of the endoprostheses remain stable during the entire observation period, their dislocation is absent, patients do not complain of pain, movements in the operated joints are not limited, they walk without crutches and canes.

A clinical example confirms the implementation of the claimed method for auto-osteoplasty of the acetabulum during revision hip arthroplasty.

Example. A 24-year-old patient in 2000 suffered a severe combined injury: a closed fracture of the right femur, neck of the left femur, a fracture of the pelvis with a rupture of the pubic joint, both ankles of the right lower leg, multiple fractures of the ribs, as a result of which, in Rostov-on-Don, osteosynthesis of fractures with metal structures, as a result of which fractures of the right thigh, ankles, lower jaw, ribs fused, but aseptic necrosis of the head of the left femur developed, as a result of which metal structures were removed in September 2001, and on March 20, 2002 Neno total arthroplasty of the left hip joint endoprosthesis cementless Spotorno (cup 48; leg 8; small head). In the postoperative period, the wounds healed by primary intention. The patient led an active lifestyle. After 4 years, pain appeared in the left gluteal region with radiation on the posterior surface of the left thigh and in the left inguinal region. She started taking NSAIDs (nimesulide, diclofenac) with a temporary positive effect. The pain syndrome progressed; on May 31, 2006, it was examined by a traumatologist and sent to hospitalization urgently. On radiographs - lysis of bone tissue around the cup and legs of the endoprosthesis. 06/07/2006, the operation was performed - removal of the endoprosthesis, revision, rehabilitation, wound drainage. After removal of the endoprosthesis, a defect in the anteroposterior wall of the acetabulum was formed. In order to close the defect, an autograft was formed from a large trochanter on the feeding leg, fixed to its bed with 3 sutures. Flow-suction drainage was established, which was carried out for 2 weeks. A histological examination of the removed tissue from the standing area of the endoprosthesis showed no signs of tumor and specific damage. 06/26/2006 revision endoprosthetics of the left hip joint was performed with a cementless endoprosthesis (Cementno Cup No. 54; Wagner's revision leg 14/225, head S) with autosteoplasty of the acetabulum with a graft of the femoral trochanter: prepared for the previous operation for a large trochanter, the bone graft on the feeding leg is mobilized, fixed to the anteroposterior edge of the acetabulum with three screws. The remaining defects are filled with spongy autografts from the iliac crest. The acetabulum is machined with spherical cutters No. 48-54. An cementless Cup No. 54 and a polyethylene liner were installed. The fixation is stable. In the postoperative period, antibacterial (thienam, metrogil), transfusion-infusion, anticoagulant and antiplatelet (aspirin, trental), symptomatic therapy, magnetotherapy, immobilization in a coxite plaster cast for 2 months were performed. After removing the plaster cast, a course of rehabilitation treatment was carried out. On radiographs after 2 years, a complete reconstruction of the graft was noted, the endoprosthesis is stable.

The inventive method allows you to close the defect in the wall of the acetabulum using an autograft from a large trochanter of the femur on the feeding leg to enable subsequent fastening in the cavity of the acetabular component of the endoprosthesis.

Information sources

1. Al-Tanani Ahmed Saeed Ahmed Mustafa. Hip replacement using reinforcing rings for protrusion and acetabular injuries. Diss ... cand. honey. Sciences (14.00.22) M., 2002, 178 p.

2. Zagorodni N.V. and others. The use of metal rings that strengthen the acetabulum during its arthroplasty / N.V. Zagorodni, H.M. Magomedov, A.L. Logunov and others // Man and his health / International Congress. - SPb., 1997. - S.35-36.

3. Magomedov H.M. Hip replacement in patients with acetabular protrusion. Diss ... cand. honey. Sciences (14.00.41., 14.00.22) M., 2000 .-- 163 s.

4. Muller RE., Diirr H.R., Wegener B., Pellengahr C., Refior H.J., V. Jansson. Internal hemipelvectomy and reconstruction with a megaprostesis // International Orthopedics (SICOT) / (2002) 76-79.

Claims (4)

1. The method of auto-osteoplasty of the acetabulum during revision hip arthroplasty, characterized in that at the first stage the endoprosthesis is removed, scars and granulations in the acetabulum are removed, the size of the acetabulum defect is determined, an autograft is formed - a bone fragment from the large trochanter is formed on the feeding leg, the autograft is fixed with a drill and fixed with two or three transosseous sutures to its bed, the wound is sutured, at the second stage, 3-4 weeks after the first stage, they are treated heel defect acetabulum with autograft removed stitches, which was fixed to his bed, to mobilize pedicled graft, is placed in the acetabulum, closing the defect is fixed to the pelvis autograft bone using screws 2-3, further establish acetabular component prosthesis. 2. The method according to claim 1, characterized in that when replacing the acetabulum defect with an autograft from a large trochanter, the remaining defects after that are replaced with spongy autografts taken from the iliac crest. 3. The method according to claim 1, characterized in that the autograft from the greater trochanter is taken on the leg from bundles of the gluteus maximus muscle. 4. The method according to claim 1, characterized in that the autograft from the greater trochanter is taken on the leg from bundles of medium and small gluteal muscle.

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